General Surgery Coding Alert

Without a careful reading of the op note, you-re probably coding incorrectly

Not all gastrostomy placements are endoscopic, and CPT actually contains four codes for procedures of this type. In addition, if your surgeon performs other procedures at the same time, you may not be able to code for the gastrostomy placement at all.

True PEG Calls for 43246

If your surgeon places a true percutaneous endoscopic gastrostomy (PEG) tube, 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) should be your code of choice.
 
What to look for: The operative note for 43246 will describe an upper GI endoscopy with insertion of the gastrostomy tube. As the code descriptor specifies, placement of this type involves both an endoscopic and a percutaneous (through the skin) component.

-Surgeons will usually place a tube of this type without performing any other abdominal procedures,- says Joshua T. Rubin, MD, of the department of surgery, Division of Surgical Oncology at the University of Pittsburgh. Generally, the purpose of the tube is either to provide nutrition (a feeding tube) or to act as a drain (in place of a nasogastric tube), Rubin says.

Percutaneous-Only Means 43750

When the physician places a gastrostomy tube percutaneously, without an endoscopic component, select code 43750 (Percutaneous placement of gastrostomy tube).
 
Guidance provides a clue: During this procedure, the surgeon punctures the abdominal wall from outside the body and inserts a device under fluoroscopic or ultrasound guidance. This allows the surgeon to pull the stomach up to the abdominal wall. The surgeon then inserts the tube percutaneously without using an endoscope, Rubin says.
 

During this procedure, the surgeon punctures the abdominal wall from outside the body and inserts a wire, which she pulls up through the mouth. She then attaches the tube and pulls it back through the mouth to the opening in the stomach. The surgeon does not use the endoscope but will usually use either ultrasound or fluoroscopy to help guide her, Rubin says.
 
Tip: You can report this ultrasound or fluoroscopic guidance separately from 43750 using 74350 (... radiological supervision and interpretation), according to CPT guidelines -- if the surgeon handles the fluoroscopy and provides the interpretation. Otherwise, a radiologist will probably report 74350 independent of the surgeon.
 

You Can Report Multiple Endoscopies

If the surgeon performs another endoscopic procedure (for instance, 43239, Esophagogastro-duodenoscopy [EGD] with biopsy) during the same session as PEG tube placement (43246), you can bill for both procedures separately. Keep in mind, however, that the -multiple-endoscopy- rule will apply. The payer will reimburse only the higher-valued procedure at 100 percent of the fee schedule amount. For the lesser-valued procedure, you will receive the standard fee schedule amount minus the value of the -base- endoscopic procedure.
 
Learn more: For complete information on the multiple-scope rule, see -Watch for -Family Ties- When Reporting Same-Day Scopes,- in the April 2006 General Surgery Coding Alert on page 25.

 

Look to 43653 for Laparoscopic Placement

 
Laparoscopic gastrostomy tube placement differs from endoscopic placement, so you should report such procedures using dedicated code 43653 (Laparoscopy, surgical; gastrostomy, without construction of gastric tube [e.g., Stamm procedure] [separate procedure]), says Linda Martien, CPC, CPC-H, coding, documentation and compliance specialist for National Healing Corp. in Mexico, Mo.
 
Watch for bundles: Most commonly, surgeons will use  this method if they already used the laparoscope for another procedure (such as to obtain a biopsy), Rubin says.
 
This is important because 43653 is a designated -separate procedure.- This means that if the surgeon performs any other laparoscopic services at the same time (such as gastric bypass or bowel resection, for instance), you can't report 43653 separately, Martien says.
     
Example: You should not report 43653 separately if the surgeon performed a laparoscopic fundoplication (43280, Laparoscopy, surgical, esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]) at the same time.
 
When you can bill: But if the surgeon uses the laparoscope for the sole purpose of placing the gastrostomy tube, you may report 43653 separately.
 
Helpful hint: -In my experience, the only time surgeons will employ the laparoscope for the sole purpose of placing a gastrostomy tube is when the patient cannot swallow an endoscope due to some technical reason,- Rubin says.
 

-Miller-Abbott- Tubes Require a Unique Code

If you run across documentation referring to a -Miller-Abbott- or long gastrointestinal tube, don't make the mistake of coding it as a PEG. Surgeons generally use the Miller-Abbott tube for drainage rather than enteral feeding.
 
Miller-Abbott tubes are longer than PEG tubes and are often used when there is some sort of obstruction. When the surgeon places a Miller-Abbott tube, you should report 44500 (Introduction of long gastrointestinal tube [e.g., Miller-Abbott] [separate procedure]).
 

43830 Describes -Open- Procedure

When the surgeon places a gastrostomy using an open approach (via a midline incision of the upper abdomen), you will report 43830 (Gastrostomy, open; without construction of gastric tube [e.g., Stamm procedure] [separate procedure]), Martien says.
 
Open gastrostomy placements are relatively rare now, Rubin says, but may occur during another, more extensive open procedure, or as a -last resort- when -- for technical reasons -- the surgeon cannot place the tube using any other method.
 
Warning: Like 43653, open placement 43830 is a -separate procedure.- Therefore, you cannot report 43830 separately if open placement takes place the same day as another procedure in the upper abdominal or stomach area.
 
For instance: The National Correct Coding Initiative bundles 43830 to 43101 (Excision of lesion, esophagus, with primary repair; thoracic or abdominal approach), among other codes.
 
This makes sense because the lesion excision occurs in the same anatomic area (and likely using the same incision) as the gastrostomy placement. Therefore, the gastrostomy is not -separate- as required by CPT coding guidelines, and you should not report it independent of 43101.