Gastroenterology Coding Alert

Tube Procedures Are Pipeline to Reimbursement

- Published on Sun, Jul 01, 2001
Appropriate coding for tube placements and replacements depends on coders distinguishing whether the gastroenterologist performed the procedure manually or endoscopically. Further, understanding the different tube variations and applications can help limit coding problems.   PEG Tube Variations   Percutaneous endoscopic gastrostomy (PEG) tube placement is reported with 43246 (upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube), says Linda Parks, MA, CPC, lead coder with the 22-physician Atlanta Gastroenterology practice. 
Physician notes sometimes contain references to buttons"" PEG buttons or ""Mickey"" buttons. These are smaller" shorter tubes that are inserted through the tract in the skin of the abdomen that was created by a standard PEG tube explains Michael L. Weinstein MD of Metropolitan Gastroenterology Group in Washington D.C. and previous American Society for Gastrointestinal Endoscopy (ASGE) representative to the CPT Advisory Board. 
"PEG buttons are used to replace a standard PEG tube after several weeks or months when the original tube tract has matured " Weinstein says. "Therefore you usually code it as a PEG tube replacement (43760 change of gastrostomy tube).
"You also might see tube descriptions with ports balloons or bumpers " Weinstein adds. "They're all tubes. MIC and Bard are just some of the brand names." Placement of these shorter tubes is still coded with 43246. Changing PEG tubes of any kind should be reported with 43760.
An Alternative to PEG Tubes   Gastroenterologists also use percutaneous endoscopic jejunostomy (PEJ) tubes explains Thomas M. Deas Jr. MD of Gastroenterology Associates in Fort Worth Texas and chairman of the Practice Management Committee of the ASGE. This is a long tube that is passed through the PEG tube into the small bowel rather than the stomach.  
There are two ways to code the PEJ tube procedure. The patient may already have a PEG tube in place and the physician has to convert it to a PEJ tube by going beyond the duodenum. This method should be reported with 44373 (small intestinal endoscopy enteroscopy beyond second portion of duodenum not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube). If the patient does not have a PEG tube coders should use 44372 (... with placement of percutaneous jejunostomy tube) for the initial PEJ tube placement. 
Code 44500 (introduction of long gastrointestinal tube [e.g. Miller-Abbott]) refers specifically to the length of a tube Weinstein explains. Longer tubes are weighted at the end (with mercury for example) and are used when there is a gastrointestinal obstruction. 
"No other procedure needs to be performed with this " Weinstein says. "The tube position usually requires checking an x-ray -- a separate billable service -- and advancing or repositioning by [...]

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