Coding Clarification: Gastrojejunal Tubes
CPT Assistant, October 2021, Volume 31, Issue 10, page 5
Endoscopic placement of feeding tubes for long-term enteral nutrition started in the early 1980s with percutaneous endoscopic gastrostomy (PEG) tubes. This type of tube enabled enteral feeding directly into the stomach. Over time, this technology has evolved.
One way gastrostomy tubes (G-tubes) have evolved is by providing jejunal feeding directly into the small bowel and bypassing the stomach. Reasons for jejunal feedings may include intolerance or recurrent aspiration of gastric feedings due to conditions that include gastroparesis, severe gastroesophageal reflux disease, or gastric outlet obstruction. Providing jejunal feedings may be accomplished by: (1) placing a jejunal extension tube through an existing PEG tube (known as a PEG-J tube); or (2) placing a single-piece gastrojejunal tube (GJ-tube) through a previous gastrocutaneous fistula or tract created by a previous G-tube. The GJ-tube is similar to a G-tube in that it includes a balloon to anchor the GJ-tube against the gastric wall; however, a GJ-tube differs because it includes a built-in extension placed in the jejunum. This article provides clarification on how to code the placement or replacement of a GJ-tube and includes questions and answers received from coders to provide further guidance.
Esophagogastroduodenoscopy
Endoscopy, Small Intestine
Initial Placement of Gastrojejunal Tubes
GJ-tube placement requires an initial G-tube placement. Subsequently, a jejunal tube is placed through the existing G-tube, and the tip of the jejunal tube is maneuvered into the proximal jejunum. This conversion from a G-tube to a GJ-tube may be performed in the same session or in a subsequent session from the placement of the initial G-tube.
If the GJ-tube is placed endoscopically, code 43246 would be reported for the placement of the PEG tube (or replacement of a larger PEG tube at the site of an original, smaller PEG tube). For the conversion of the PEG tube to a PEG-J tube, code 44373 would be reported if the jejunal portion is advanced beyond the second portion of the duodenum under endoscopic guidance. Report code 43241 if only an esophagogastroduodenoscopy (EGD) was performed, and the GJ-tube is advanced into the jejunum without endoscopic guidance. If both PEG tube placement and the conversion to GJ-tube are performed in the same session, report codes 43246 and 44373, if the jejunal portion is advanced beyond the second portion of the duodenum under endoscopic guidance.
If the GJ-tube is placed under fluoroscopic guidance, code 49440 would be reported for placement of the G-tube. For the conversion of the G-tube to a GJ-tube in a separate session, code 49446 would be reported. If both G-tube placement and the conversion to GJ-tube are performed in the same session, codes 49440 and 49446 would be reported with modifier 59, Distinct Procedural Service, appended.
Introduction
Endoscopy, Small Intestine
Replacement of Gastrojejunal Tubes
GJ-tube replacement (eg, for a clogged tube) may be performed endoscopically or with fluoroscopic guidance. A GJ-tube replacement involves placing a gastric balloon replacement tube into the stomach and extending the tube beyond the balloon to place it into the small intestine (ideally into the jejunum beyond the Trietz ligament) by endoscopy, under fluoroscopic guidance, or by simple peristalsis.
If the GJ-tube is replaced endoscopically, code 44373 would be reported if the endoscopic portion is advanced beyond the second portion of the duodenum. Code 43241 would be reported only if an EGD was performed and the GJ-tube was pushed to the appropriate location.
If the GJ-tube is replaced under fluoroscopic guidance, report code 49452.
If the GJ-tube was replaced without imaging or fluoroscopy or endoscopic guidance, code 43762 would be reported. This assumes the replacement GJ-tube is placed into the stomach and anchored in place by inflating the gastric balloon with water or saline and that there is no revision of the gastrocutaneous fistula (tract). Peristalsis would carry the jejunal portion of the tube into the small intestine. The only physician work is placing the GJ-tube into the stomach; therefore, it would be appropriate to report code 43762. If revision of the gastronomy tract is required, code 43763 would be reported.
The American Medical Association's (AMA's) CPT® Network often receives questions about correct coding of GJ-tube procedures. Following are questions and answers to provide further clarification of these procedures.
Question:
What is the appropriate code to report for an endoscopic GJ-tube change?
Answer:
It would be appropriate to report code 44373, Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube, if an enteroscopy is performed (endoscopy to jejunum, at least 50cm beyond pylorus), or code 43241, Esophagogastroduodenoscopy [EGD], flexible, transoral; with insertion of intraluminal tube or catheter, if only an EGD endoscopy is performed in advancing the jejunal tube portion into the small bowel. Code selection depends on the extent of the endoscopic examination when placing the jejunal portion of the GJ-tube.
Question:
What is the appropriate code to report for a GJ-tube changed with imaging or fluoroscopy?
Answer:
This procedure is typically performed by a radiologist and is reported with code 49452, Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.
Question:
What is the appropriate code to report a GJ-tube change without imaging, fluoroscopy, or endoscopy?
Answer:
It would be appropriate to report code 43762, Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract, assuming the replacement GJ-tube is placed into the stomach and anchored in place by inflating the gastric balloon with water or saline and that there is no revision of the gastrocutaneous fistula (tract). If revision of the tract is required, then code 43763 would be reported. Peristalsis would carry the jejunal portion of the tube into the small intestine; therefore, the only physician work is placing the GJ-tube into the stomach, which is why it would be appropriate to report code 43762.
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