General Surgery Coding Alert

Following various abdominal procedures, patients often are malnourished and the general surgeon will insert a tube to nourish the patient.

Typically, the surgeon will perform a jejunostomy
(J-tube) or a gastrostomy (G-tube), depending on the location of the primary procedure.

When performing the most common type of jejunostomy, CPT 44015 (tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method [list separately in addition to primary procedure]), the surgeon makes an abdominal incision and chooses a section of proximinal jejunum. A jejunostomy tube (J-tube) is then placed in the jejunum and brought out through the abdominal wall. The selected section of jejunum is tacked to the inside of the abdominal wall, and then the incision is closed.

With 43830 (gastrostomy, temporary [tube, rubber or plastic][separate procedure]), the most likely gastrostomy during abdominal surgery, the physician makes a midline incision in the upper abdomen and selects a gastrostomy site on the middle anterior surface of the stomach. Stay sutures are placed and a small stab wound is made between purse string sutures. A gastrostomy tube (G-tube) is inserted and the purse string sutures are tied. The G-tube is withdrawn through a stab wound in the abdominal wall and stay sutures are placed in the posterior fascia. Then the abdominal incision is closed.

Understanding In addition to is Crucial

Although both procedures serve a similar purpose (i.e., to feed the patient) and vary primarily by the site of the tube, they are reimbursed differently by payers.

Gastrostomy (43830) is listed as a separate procedure, which means surgeons cannot bill for it if it took place the same day as another procedure in the upper abdominal or stomach area. For lower abdominal procedures, it is not considered separate and may be billed, according to Arlene Morrow, CPC, a general surgery coding consultant in Tampa, FL.

On the other hand, 44015, the most common type of jejunostomy, is described in CPT 1999 as a list in addition to code, meaning that it should be billed over and above the primary procedure, Morrow says.

So when a jejunostomy is performed during the same day as another procedure, such as a partial colectomy (44140), the code is listed separately and reimbursed at 100 percent of its normal rate (which, as an in addition to code, has already been reduced to be intraoperative only, which means payment is for the procedure only, not for any pre- or post-operative work).

Another important characteristic of in addition to codes is that they cannot be billed on their own, only in conjunction with another procedure. This means that:

44015 may be listed in addition to any procedure code between 40490 to 58999; that is to say, it can be billed along with any abdominal procedure in which the patient is malnournished and will need supplemental nutrition. The J-tube insertion will not be bundled with anything.

Coding the insert of a J-tube (44015) with a -51 modifier to indicate it is a secondary procedure is incorrect, and the most frequent result will be denial of the claim.

If the jejunostomy is performed on its own, then 44015 would not be appropriate. However, you can bill for it using code 44300 (enterostomy or cecostomy, tube [e.g., for decompression or feeding] [separate procedure]). Because 44300 is a separate procedure, it can only be billed when it is not performed in conjunction with another abdominal procedure. The 44015, meanwhile, can only be listed in addition to another abdominal procedure at a nearby site.

So, if a patient is scheduled for a jejunostomy and the surgeon removes skin lesions at the same time, the J-tube procedure should be coded with 44300, not 44015, because the second procedure (the removal of the lesions) is not an abdominal procedure.

Note: The CPT 1999 book lists all in addition to codes with a + symbol to the left, another reminder not to use the -51 modifier.

Say, for example, the general surgeon performs a colon resection (44144, colectomy, partial, with resection, with colostomy or ileostomy and creation of mucofistula). He also inserts a feeding J-tube (44015) and a G-tube (43830) to decompress the patient. As a list in addition to code, the 44015 is billable. So is the 43830 (because the primary procedure is in the lower abdomen), but only as a secondary procedure. The 44145 would be listed first, followed by the 43830 and the 44015.

According to the Medical Carriers Manual, Section 15038, when more than one surgical service is performed on the same patient, by the same physician and on the same day, the fee schedule amount for a second procedure is 50 percent of the fee schedule amount that would have been otherwise applicable for that procedure, and are indicated by using modifier -51 (multiple procedures).

You Can Bill J-tube Complications

Because a jejunostomy coded 44015 is an in addition to code, it has no global period. This is significant, for example, if a patient with colon cancer has a colectomy and receives a J-tube for feeding. The J-tube may remain with the patient during the course or his or her hospital stay and even after discharge, or it may be removed once the patient is able to eat.

Either way, because the 44015 has no global period, any complications specific to the J-tube itself are billable, says Karen Evans, RN, CCS-P, a general surgery reimbursement specialist in Mount Vernon, WA.

Evans also emphasizes that when coders bill for services, they must read the surgeons operative report. Often, the surgeon hands coders only a billing slip and charge slip. However, in order to code such procedures (and most others) correctly, they also should look at the op report and the pathology report, which will help them determine the surgical, as opposed to the pre-operative, diagnosis.