General Surgery Coding Alert

Question: Sometimes our surgeon removes a previously-placed PEG tube during an office visit. Occasionally, the surgeon will percutaneously remove and replace a PEG tube during an office visit. When the surgeon needs to relocate the PEG tube, it involves an EGD to place a new tube in a different location, plus removing the old tube. Based on the reader question "43246 Includes Removal" in General Surgery Coding Alert Vol. 13 No. 4, I would like a clarification -- how should we code each of these scenarios?

Ohio Subscriber

Answer: You would report only 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) in the relocation scenario you outlined above -- which was the scenario addressed in the reader question. When the surgeon performs an esophagogastroduodenoscopy (EGD) to place a new percutaneous endoscopic gastrostomy (PEG) tube, and also removes an old tube from a different location, you should report 43246. The PEG tube removal is bundled with the placement of the new tube.

On the other hand: If the physician simply removes a PEG tube during an office visit, you should report the appropriate E/M service for the office visit, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Office replacement: For percutaneously removing and replacing the PEG tube in the physician office, you should list procedure code 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance) in addition to a code for any distinct, separately identifiable E/M service on the same day (such as 99213). You'll need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.