Two-man vs. One-man PEG Tube Placements Cause Confusion
Published on Fri Oct 01, 1999
PEG tube placements are used when patients are unable to eat or swallow, according to Kathy Anderson, RN, the director of nursing and plant manager of the Indianapolis Endoscopy Center, an ambulatory surgical center serving four gastroenterologists. She believes most of the patients receiving the feeding tube are in a debilitated and fragile state and are often stroke victims.
The placement procedure has multiple steps that require two sets of hands. The gastroenterologist first performs an upper gastrointestinal endoscopy, which is done to locate the desired position for the tube along the wall of the stomach. Once the position is marked, an incision is made into the wall of the stomach. The PEG tube is then fed over the endoscope and held in place with a retention disk.
Two Physicians Not Required
The source of the coding confusion for PEG tube placements comes from the shift away from using a gastroenterologist and a surgeon to perform this procedure toward the less expensive combination of a gastroenterologist and a nurse or other technician. If a nurse or technician is helping with the placement, the gastroenterologist locates the desired position of the tube before handing the scope over to his or her assistant. The gastroenterologist then makes the incision and puts the tube into place.
When PEG tubes first came out, it was believed that the procedure was fraught with danger that a nurse could not take care of, says Anderson, adding, in many hospitals, the accepted practice is still to have one surgeon and one gastroenterologist perform the procedure.
She adds, however, now the feeling among many is that this is easy. Why do we need another doctor in the room?
Two Coding Situations
The Health Care Financing Administration (HCFA), which administers Medicare, must have been thinking the same thing because it does not reimburse fully for the services of two physicians for this procedure.
Referring to the CPT Assistant (Spring 94), Pat Stout, CMT, CPC, and a consultant to the American College of Gastroenterologists, outlined two national standards for coding a PEG tube placement:
1. One gastroenterologist, one nurse. Use code 43246 (endoscopy with directed placement of percutaneous gastrostomy tube) without a modifier. The physician will receive 100 percent of the allowed amount. There is no extra reimbursement for the services of the nurse.
2. Two physicians (two gastroenterologists or one gastroenterologist and one surgeon). In this situation, first list 43246-62 (modifier -62, two surgeons), which represents the upper gastrointestinal endoscopy done by the gastroenterologist. Then list 43246-62 again to cover the making of the incision by the surgeon or second gastroenterologist. Each physician will receive 62.5 percent of the allowed amount. Total reimbursement should be [...]
