EGD Peg-J tube placement under fluoroscopic


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Looking for help for this case. I'm thinking 43246 and 49441.

The patient was prepped and draped in the usual sterile fashion in supine
position. A gastroscope was inserted through the upper esophageal
sphincter, with direct digital manipulation advanced down to the level of
the GE junction. The esophagus was free of masses, ulcers, varices or
strictures. Stomach was entered and was easily distensible. The pylorus
was widely patent and the duodenum was visualized. The duodenum was
edematous from the pancreatitis, it would appear. There was no sign of
hemorrhage or erosion. The ampulla was not visualized. The scope was
withdrawn in the stomach. The stomach was free of masses, ulcers, varices
or any other abnormalities. The duodenum, of note, was free of masses,
ulcers or varices as well. Transilluminated to the anterior abdominal
wall. There was good 1:1 indentation. There was low suspicion of
underlying visceral structure. A transverse incision was made in the skin.
A large bore Angiocath was advanced into the gastric lumen. A wire was
advanced down the sheath. Snare with a scope pulled out through the
oropharynx. A 24 French pull peg was hooked to the wire and pulled out
through the anterior abdominal wall in the traditional pull peg technique.
The bolster was placed at the skin. I readvanced the scope down and the
peg bolster on the inside, it appeared to be submucosal. Therefore, the
tube was removed. We readvanced the sheath back into the stomach in the
same position. A wire was advanced once more and hooked to the PEG after
it was brought out through the oropharynx and pulled out from the anterior
abdominal wall. This time, the scope was brought down. The bolster
appeared to be in good position. A snare was advanced down the PEG, opened
and closed around the scope. The scope was taken down to proximal jejunum.
A stiff shaft 0.035 HydroGlide wire was advanced to the proximal jejunum.
I then withdrew the scope. The snare was opened and closed around the wire
which pulled out through the PEG tube. A 12 French PEG J-tube was advanced
over the wire into the proximal jejunum with no kink. Contrast study
showed it to be in good position. It was locked with saline. The patient
was then awakened and transferred to Recovery in satisfactory condition
tolerating the procedure well.


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I did not see where fluoroscopy was used. I read it to be an EGD w/ PEG placed and then PEG converted to PEJ. I code these as 43246 & 44373-XS if it is a Medicare payer. I would use a -51 modifier if commercial, which is what I used with Medicare payers before we had the X modifiers.