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NOTES: endoscopic repair of gastrocutaneous fistula

Eleen Posted Thu 03rd of November, 2016 12:53:00 PM
A previously placed G-J tube was seen. The tube was removed. The gastrostomy tract was then de-epithelialized with APC. The tract was then closed with two over the scope clips. The exam of the stomach was otherwise normal. Do I code CPT 43255
SuperCoder Answered Fri 04th of November, 2016 03:34:15 AM

CPT code 43255 is not the appropriate code for removal of GJ tube as this code refers to EGD performed with control of bleeding.

For manual removal of GJ tube, you should report a low-level E/M code, probably 99212 (Established patient office visit). The doctor can qualify for a level-two service by meeting two criteria: a problem-focused history, a problem-focused examination or straightforward medical decision-making. He or she can qualify for 99212 by: 

·  including a statement on the purpose for removing the tube (history)

·  examining the abdomen around the tube and inspecting the condition of the tube tract after removal (examination).

If complications such as bleeding or pain arise, the office visit may result in a higher-level E/M based on increased time, examination or decision-making.

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