Wiki Peg / Trach Removal

[jboes41527]

I've got concerns with docs using our GI rooms for removal of Peg tubes, and most recently a removal of a trach tube. I'm accumilating charges for supplies, meds, often recovery room time - yet - I have no procedure to actually code. Any suggestions or thoughts on this??

 

[FTessaBartels]

Anesthesia required?

When our pediatric patients require a trip to the OR for removing these tubes under anesthesia we use 43999 Unlisted code.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[jboes41527]

We're not using anesthesia for these, from the documentation, I understand these to be quite simple procedures that could possibly done in an outpatient clinic setting, and no our GI suites.

 

[FTessaBartels]

Part of E/M

If you're not using anesthesia, they you're stuck with the "procedure" being part of an E/M service.

However, if the patient is being observed for some time post procedure, you MIGHT have prolonged service. It all dependso on the documentation, of course, but additional time of 30 minutes or more can be coded over and above the basic E/M service.

F Tessa Bartels, CPC, CEMC