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Hint: You can’t use the code for every EGD procedure.

The CPT^® code range for esophagogastroduodenoscopy (EGD) procedures is 43235 to 43259; savvy coders know how to find the most precise fit for a patient depending on the specific circumstances and reasons for their procedure. For example, when a provider performs an EGD procedure to place a percutaneous gastrostomy tube, you’ll use 43246 (Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube).

During a percutaneous endoscopic gastrostomy (PEG) procedure, a provider places a feeding tube with guidance from a flexible endoscope.

Read on to learn more about this procedure and best coding practices for 43246.

Understand the PEG Procedure

Gastrostomy tubes help people receive nutrients if they are unable to eat or drink by mouth enough to sustain themselves. Often, patients who undergo PEG have a condition that inhibits their ability to swallow. Some examples of diagnoses that may necessitate a PEG procedure include:

• Neurological conditions like Parkinson’s disease, dementia, or stroke
• Cancer in the head, neck, mouth, or throat
• Trauma, such as a brain injury or severe burn to the face
• Esophageal strictures
• Reduced consciousness or coma

The goal of the PEG procedure is to create a safe means for patients to stay hydrated and receive nutrients or medication. Patients with gastrostomies can still consume solids or liquids orally after their procedure if they are able.

During a PEG surgery, the provider inserts a gastrostomy tube through the abdominal wall directly into the patient’s stomach. The endoscope, which the provider inserts through the patient’s mouth, gives the provider increased visibility and helps them accurately place the gastrostomy tube.

As with any surgery, there are risks associated with PEG. That is why providers should only perform a PEG procedure if the benefits — long-term nutritional support that does not require the patient to eat or drink by mouth — outweigh the risks of complications, which include infection, bleeding, and perforation of the gastrointestinal (GI) tract.

Avoid These Common Mistakes With 43246

Keep in mind that 43246 is only applicable if there is ample documentation for both the diagnostic (using the endoscope to visualize the GI tract) and therapeutic (placement of the gastrostomy tube) aspects of the procedure. Do not use 43246 if the provider performs a separate EGD procedure without an intent to place a gastrostomy tube. This code is solely meant for cases where the providers place the tube and use an endoscope to visualize the GI tract from the mouth to the stomach during the same surgery.

If you do not see a clear indication in the patient’s medical record that the surgery involved the placement of a gastrostomy tube, do not use 43246. Instead, see if a different CPT^® code in the set for EGD procedures is a better fit.

For example, if instead of placing a gastrostomy tube the provider dilates a gastric or duodenal stricture, use 43245 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) eg, balloon, bougie). Or, if the provider removes a foreign body, use 43247 (Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)).

Use Modifiers With 43246 When Appropriate

Several modifiers can apply to 43246.

If there is a change to the services the patient receives or if the patient receives another service during the postoperative period, know that you may need to append one of these modifiers to your procedure code:

• Modifier 22 (Increased procedural services)
• Modifier 26 (Professional component)
• Modifier 52 (Reduced services)
• Modifier 53 (Discontinued procedure)
• Modifier 59 (Distinct procedural service)

For example, modifier 53 represents cases where there are extenuating circumstances or a patient’s health is threatened to the extent that the provider discontinues the procedure. You would use modifier 53 if a patient’s life was in danger during their PEG procedure, and as a result their provider stopped the surgery.

If a patient returns to the operating room after a PEG procedure, you may need to apply one of the following modifiers:

• Modifier 76 (Repeat procedure or service by same physician or other qualified health care professional)
• Modifier 77 (Repeat procedure by another physician or other qualified health care professional)
• Modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period)

For example, if for any reason the patient needs their gastrostomy tube to be placed again, you would use modifier 76 if the same physician who performed the original PEG does the second surgery; and you would use modifier 77 if a different physician performs the second surgery.

Also, depending on the personnel present during the PEG procedure, you may need to apply one of these modifiers:

• Modifier 80 (Assistant surgeon)
• Modifier 81 (Minimum assistant surgeon)
• Modifier 82 (Assistant surgeon (when qualified resident surgeon not available))
• Modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery)
• Modifier GC (This service has been performed in part by a resident under the direction of a teaching physician)
• Modifier QX (CRNA service: with medical direction by a physician)
• Modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)
• Modifier QZ (CRNA service: without medical direction by a physician)

For example, if a physician assistant (PA) or nurse practitioner (NP) assists with a PEG procedure, use modifier AS.

Remember These Tips When Assigning 43246

While there are many codes in the EGD code set, remember that you should only use 43246 if the patient’s medical record indicates that the provider placed a gastrostomy tube while visualizing the GI tract with an endoscope. If that is the case and you select 43246, be sure to check to see which, if any, modifiers apply.

If you are coding for a patient who had an EGD procedure but did not have a PEG, refer to CPT^® codes 43235-43259 to determine which code is the best fit.

Michelle Falci, BA, M Falci Communications LLC