Radiology Coding Alert

Confusion over coding the various scenarios inherent with placement, repositioning and exchange of gastrostomy and gastrojejunostomy tubes can be avoided by using the correct codes in response to specific patient situations.

Billing for Placement of New Tubes

Placement of a new gastrostomy tube entails the physician making a small incision through the skin and fascia of the patients abdomen, according to Cindy C. Parman, CPC, CPC-H, of Coding Strategies, Inc. in Atlanta, a firm that supports 1,000 radiologists, 50 radiation oncologists and 300 physicians from other specialty areas. Parman referred to MediCodes Coders Desk Reference. A large bore needle with a suture attached is passed through this incision into the lumen of the stomach. The physician then inserts a snare through the patients mouth and esophagus. This device is used to grab the needle, suture the stomach and pull both up and out the mouth. The gastrostomy tube is then connected to the suture and passed through the mouth, down to the stomach and out the stomach wall. Sutures then hold the gastrostomy tube in place.

Correct coding for this initial placement is 43750 (percutaneous placement of gastrostomy tube). Radiologic supervision and interpretation for this procedure is 74350 (percutaneous placement of gastrostomy tube, radiological supervision and interpretation).

The procedure for placement for a gastrojejunostomy (G-J) tube is similar, but coders must be aware that either a single- or dual-lumen jejunostomy tube may be introduced. Physicians will make an abdominal incision and mobilize the small bowel. A long intestinal tube is placed into the lumen of the proximal small bowel and threaded through the full length of the small intestine. The tube is brought out through the abdominal wall and the jejunum at the site of the tube is anchored to the inside of the abdominal wall.

The Society for Cardiovascular and Interventional Radiology (SCVIR) in its Coding Users Guide notes the following alternative coding scenario for new gastrojejunostomy tube placement: 43750 and CPT 44373 (small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube). These would be accompanied by radiological supervision and interpretation code 74355 (percutaneous placement of enteroclysis tube, radiological supervision and interpretation). If the procedure involves a dual lumen, 74350 should be added.

Coding Alert: Various states and carriers may recommend different coding approaches for G-J tubes. We strongly advise that you check with your local medical directors to determine their policies.

Converting and Changing GI Tubes Coding

In some instances, the radiologist will be called upon to convert an indwelling gastrostomy tube to a single or dual-lumen gastronjejunostomy tube. CPT procedure code 43761 (repositioning of the gastric feeding tube through the duodenum for enteric nutrition) would be assigned, accompanied by 74355. Radiological supervision and interpretation code 74350 would be added if a dual lumen is involved.

If the gastrostomy tube is changed for some reason, CPT code 43760 (change of gastrostomy tube) would be assigned, accompanied by 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g. gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation).

Changing a single- or dual-lumen gastrojejunostomy tube with repositioning of the gastric and jejunal ports over a wire would be coded 43761 and 75984, with 74350 added for a change involving a dual lumen.

Options When a G-J Tube is Dislodged

Replacement of a dislodged gastrojejunostomy tube can be handled several ways. The best option is for coders to discuss which coding scenario their local carriers favor.

If replacement of a dislodged G-J tube is simple because the existing tract is open and patent, many coders will code the procedure exactly as they would code changing a gastrojejunostomy tube: 43760 with 75984, and 74350 if the change involved a dual lumen.

If the track is closed, a sinography with fluoroscopy will be required to renegotiate and redilate the track. Coding for this scenario most likely would be 44373 with 74355. In addition, 43750-52 (percutaneous placement of gastrostomy tube; reduced services) will be added. Again, if a dual lumen is involved, 74350 also may be added.

However, some professionals note that this constitutes a return to the operating room for a related procedure during the postoperative period. In this case, the professional coder may code the replacement of a dislodged tube with a -78 modifier (return to the operating room for a related procedure during the postoperative period). If, for instance, the replacement of the dislodged tube is considered simple and occurs during the 10-day global surgical period of the initial tube placement, the alternate coding would be 43760/75984.

Proper coding of any of these procedures depends upon the work involved, particularly with tube exchanges, cautions Parman, and, of course, it can be coded and billed only if your physician has documented it all clearly.