Jennifer Posted Thu 13th of June, 2013 20:04:45 PM
My doctor performed an EGD with biopsy but also removed and then replaced a J-Tube. This was done without fluoroscopy. Could you please advise me on how to code this. I was looking at CPT code 49451 but this specifically states "under fluoroscopic guidance" so I am uncomfortable using this code. Any help would be greatly appreciated. Thank You.
SuperCoder Answered Fri 14th of June, 2013 02:06:23 AM
There is no specific code for replacing a pre-existent J tube; therefore, unlisted code 44799, Unlisted procedure, intestine, may be reported.
Alternatively, the intensity of the service may be reflected in the "procedural risk" consideration of the medical decision-making component of the evaluation and management service.
If the tube replacement requires imaging guidance, code 49451, Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report, may be reported.
When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, a procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.