General Surgery Coding Alert

Because they often require replacement and have both a percutaneous and endoscopic component, percutaneous endoscopic gastrostomy (PEG) tubes present unique coding challenges. PEG codes vary considerably, depending on (a) whether the tube is being placed, replaced or removed and (b) whether endoscopy was used, and if so, the final location of the scope.

Coding for Tube Placement

If a new PEG tube is placed with a scope, 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 reported. If the surgeon also performs another endoscopic procedure (i.e., 43239, esophagogastroduodenoscopy [EGD] with biopsy) during the same session, both procedures may be separately billed, but the multiple-endoscopy rule applies and therefore the highest-paid of the two procedures (43246, 7.21 relative value units [RVUs]) will be reimbursed at 100 percent of the fee schedule. The fee for the second procedure (in this case, 43239, 4.59 RVUs) is calculated by subtracting the RVUs from base endoscopy code 43235 (4.59 - 4.11 = 0.48 RVUs).

Sometimes two surgeons, often a general surgeon and gastroenterologist, perform the surgery together. In these situations, one physician may incorrectly bill a diagnostic endoscopy (43200 or 43235) while the other bills the PEG placement (43246).

Instead, both surgeons should bill 43246 separately with modifier -62 (two surgeons) attached, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill. Medicare should pay the procedure at 125 percent (or 62.5 percent per physician), as long as both surgeons bill and document the session separately.

Note: Some carriers only pay for an assistant surgeon for PEG tube placement. If that is the case, the assistant surgeon should attach modifier -80 (assistant surgeon) to the claim. Reimbursement for the procedure is significantly lower (16 percent of fee schedule), but a separate report is not required.

Use 43760 for Tube Replacement

PEG tubes often require replacement due to clogging or other factors. The replacement may be performed percutaneously, endoscopically or via a combination of both techniques. If a PEG tube is replaced and the entire procedure is done percutaneously, only 43760 (change of gastrostomy tube) should be used.

Note: Code 43750 (percutaneous placement of gastrostomy tube) should not be used when the tube is replaced. This code includes creation of a new tunnel for the tube, which is not usually performed at the time of replacement.

Sometimes, the surgeon may encounter a problem replacing the tube. For example, if the surgeon is unable to move the tube, a diagnostic endoscopy may be performed to determine the problem and assist in the tube removal. The surgeon then places the replacement PEG tube percutaneously, without using the scope.

In this instance, Mueller says, the diagnostic endoscopy and 43760 may be separately billed. In most cases, even though gastroscopy is performed to determine the nature of the problem in the stomach, only an esophagoscopy (43200) can be billed. Sometimes, however, an x-ray or symptom may indicate a possible abnormality beyond the pylorus and the surgeon performs an EGD (43235) to check it. In such cases, the reason for the EGD (in particular, why it was necessary to go beyond the pylorus) should be documented in the patients chart.

Although 43760 is bundled with 43235 in the national Correct Coding Initiative (version. 7.1), the edit has a 1 indicator, which means that the appropriate use of modifier -59 (distinct procedural service) will override the edit. Appending modifier -59 to 43760 lets the carrier know the PEG tube was placed percutaneously, not endoscopically. If the new tube is placed endoscopically, only 43200 or 43235 should be billed.

Note: Codes 43246 and 43247 (removal of foreign body) should not be used to report the replacement of a PEG tube.

Bill E/M for Tube Removal

There is no code for the removal of a PEG tube. If the surgeon removes the tube only, an appropriate-level outpatient E/M code (99201-99215) should be billed, Mueller says. Taking out a PEG tube, she adds, does not constitute removal of a foreign body: 43247 should not be used to report this service.

The only time 43247 is appropriately used in these situations is if the tip of the PEG tube breaks off and the surgeon has to remove it, Mueller says.

If a diagnostic endoscopy was required to remove the tube (due to complications, for instance), the appropriate endoscopic procedure code (43200, or 43235 in some cases) may be billed.

Replacement of Mushroom Basket

The PEG tube is held in place by a mushroom-shaped basket, or bolster, on the inside of the stomach wall. Sometimes this device needs to be replaced, which involves the surgeon using endoscopy to go back into the stomach.

When this occurs, the replacement of the device may be coded using 43246; however, because no new tunnel for the tube needs to be created, modifier -52 (reduced services) should be appended to 43246 to indicate that the surgeon bolstered the tunnel only and did not replace it.