An interventional radiologist may place, replace or maintain any of several types of gastrointestinal (GI) tubes, including gastrostomy tubes, duodenostomy or jejunostomy tubes, cecostomy or other colonic tubes, and gastro-jejunostomy tubes

Initial tube placement

For initial, percutaneous insertion of a gastrostomy tube, without using an endoscope and including radiologic supervision and interpretation, report 49440 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. The procedure involves a puncture through the abdominal wall from outside the body, with device insertion under fluoroscopic or ultrasound guidance. The stomach is pulled up to the abdominal wall, and the tube is inserted percutaneously.

Code 43246 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube also describes initial placement of a gastrostomy tube, but using an endoscope and without fluoroscopic guidance. An interventional radiologist would not typically perform a procedure of this type.

For percutaneous insertion of a duodenostomy or jejunostomy tube, report 49441 Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. For similar insertion of a cecostomy or other colonic tube, the appropriate code choice is 49442 Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.

The gastro-jejunostomy tube is a dual-lumen feeding tube. The gastric lumen may be used for decompression, for instance, while the jejunal lumen administers nutrition.

There is no single code to report initial placement of a gastro-jejunostomy tube. Instead, first report the gastrostomy tube placement using 49440, then follow with 49446 Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. AMA instructions in CPT specifically allow this code combination, stating, "For conversion to a gastro-jejunostomy tube at the time of initial gastrostomy tube placement, use 49446 in conjunction with 49440."

To report conversion of an existing gastrostomy tube into a gastro-jejunostomy tube, claim 49446 only.

Note that all of the above placement codes include radiologic supervision and interpretation. Do not attempt to report additional codes for guidance, contrast injection(s), image documentation and report.

Tube replacement

GI tube replacement may be more common than initial placement for interventional radiologists. These services come with a specific set of CPT codes, and should not be reported using initial placement codes 49440-49442, or 49946.

When the physician replaces a gastrostomy tube under fluoroscopic guidance, select 49450 Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. Note that 49450 is appropriate for change of a cecostomy or other colonic tube, as well.

Do not confuse 49450 with 43760 Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance. The latter code describes gastrostomy tube replacement without imaging guidance, which an interventional radiologist is unlikely to perform.

To report percutaneous replacement of a duodenostomy or jejunostomy tube, select 49451 Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. For similar replacement of a gastro-jejunostomy tube, call on 49452 Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.

As with insertion codes 49440-49442, tube replacement codes 49450-49452 include fluoroscopic guidance. To reflect this, the AMA revised code 75984 Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation for 2008 to remove reference to the gastrointestinal system.

Tube maintenance

Additional codes describe maintenance services for all types of GI tubes. These include 49460 Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report for mechanical removal of obstructive material by any method; and 49465 Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report to describe radiological evaluation of an existing GI tube via a percutaneous approach. Both 49460 and 49465 include fluoroscopic guidance.

G. John Verhovshek, MA, CPC, is director of clinical coding communications for the American Academy of Professional Coders (http://www.aapc.com/), an organization that provides certification to medical coders in the physician office, outpatient facility, and payer environments.