Procedures Utilizing the Entuit® Gastrostomy

Procedures Utilizing the Entuit® Gastrostomy Feeding Tube
Product Line
20 CODING AND REIMBURSEMENT GUIDE
Coverage, coding and payment for medical procedures and devices can be confusing. This guide was developed to
assist with Medicare reporting and reimbursement when using the Entuit® Gastrostomy Feeding Tube Product Line. If you
have any questions, please contact our reimbursement team at 800.468.1379 or by e-mail at
[email protected]
Coverage
Medicare carriers may issue Local Coverage Decisions (LCD’s) listing criteria that must be met prior to coverage.
Physicians are urged to review these policies (http://www.cms.hhs.gov/mcd/search.asp) and contact their carrier’s local
medical director (www.cms.hhs.gov/apps/contacts), or commercial insurers to determine if a procedure is covered.
Coding
Gastrostomy procedures are typically reported using the following Current Procedural Terminology (CPT) codes:
Placement
Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image
documentation and report
49440
NOTE: It is not necessary to report 43752 for placement of a nasogastric (NG) or orogastric (OG) tube to insufflate the stomach
prior to the procedure as it is considered integral to 49440.
Replacement
43760
Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance
49450
Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including
contrast injection(s), image documentation and report
Removal
The manual removal of a gastrostomy tube would be included in the Evaluation and Management Service provided on that date. If only
the removal of the gastrostomy tube was provided (i.e. no other E/M effort was provided that date), then the appropriate E/M code
should be reported based on the key components performed to remove the gastrostomy tube on that date.1
Gastropexy
Do not report gastropexy separately when performed in conjunction with gastrostomy tube placement as it is included in the work of
49440.2
1
2
CPT® Knowledge Base. American Medical Association. KB #5093. March 2007.
CPT® Knowledge Base. American Medical Association. KB Vignette for 49440.
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
Disclaimer: The information provided herein reflects Cook’s understanding of the procedure(s) and/or device(s) from sources which may include, but are not limited to, the CPT, ICD-9 and
MS-DRG coding systems; Medicare payment systems; commercially available coding guides; professional societies; and research conducted by independent coding and reimbursement
consultants. This information should not be construed as authoritative. The entity billing Medicare and/or third party payers is solely responsible for the accuracy of the codes assigned to
the services and items in the medical record. Cook does not, and should not, have access to medical records, and therefore cannot recommend codes for specific cases. When making
coding decisions, we encourage you to seek input from the AMA, AHA, relevant medical societies, CMS, your local Medicare Administrative Contractor and other health plans to which you
submit claims. Cook does not promote the off-label use of its devices.
Effective January 1, 2015 - March 31, 2015
Inpatient Hospital
Hospitals use the ICD-9 Procedure Coding System to describe procedures performed during hospital admissions. The following are
examples of procedure codes that may be pertinent for a given hospital admission.
Facilities coding for gastrostomy procedures should consider:
Placement
43.19
Other gastrostomy
Replacement
97.02
Replacement of gastrostomy tube
Removal
97.51
Removal of gastrostomy tube
Gastropexy
Gastropexy
44.64
3
NOTE: Do not report gastropexy suture of the stomach to the fascia separately when performed as an inherent part of
gastrostomy to prevent leakage.3
ICD-9-CM for Hospitals and Payers – Volumes 1, 2 & 3. Eden Prairie, MN: OptumInsight. © 2014
The procedures noted above are rarely performed on an inpatient basis, and if they are, they are unlikely to be the primary reason for a
hospital admission. Without knowing the primary reason for admission, or what other procedures may have been performed during the
admission, it is not feasible to prospectively identify to what DRG(s) patients undergoing these procedures would be assigned.
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
Disclaimer: The information provided herein reflects Cook’s understanding of the procedure(s) and/or device(s) from sources which may include, but are not limited to, the CPT, ICD-9 and
MS-DRG coding systems; Medicare payment systems; commercially available coding guides; professional societies; and research conducted by independent coding and reimbursement
consultants. This information should not be construed as authoritative. The entity billing Medicare and/or third party payers is solely responsible for the accuracy of the codes assigned to
the services and items in the medical record. Cook does not, and should not, have access to medical records, and therefore cannot recommend codes for specific cases. When making
coding decisions, we encourage you to seek input from the AMA, AHA, relevant medical societies, CMS, your local Medicare Administrative Contractor and other health plans to which you
submit claims. Cook does not promote the off-label use of its devices.
Effective January 1, 2015 - March 31, 3015
Payment
201 Medicare Reimbursement for Gastrostomy Procedures
The Protecting Access to Medicare Act (PAMA) of 2014 provides for a zero percent update to the Medicare Physician Fee Schedule
for services furnished between January 1, 2015 and March 31, 2015. This law postpones a 21.2% payment reduction for physicians
and other practitioners who treat Medicare patients from taking effect on January 1, 2015. The Physician Fee Schedule amounts
below reflect this temporary update. For further questions regarding the physician fee schedule, please contact the Reimbursement
Department via e-mail at [email protected] or 800.468.1379.
Ambulatory
Surgery
Center
CPT®
Code
Outpatient Hospital
Facility
Payment
Procedure Description
Physician Services
Facility
Payment
Fee When
Procedure
Is Performed
in Hospital
or ASC
Fee When
Procedure
Is Performed
in Office
(National Medicare Avg6)
(National Medicare Avg4)
APC
(National Medicare Avg5)
(National Medicare Avg6)
$583.67
0419
$1,064.45
$231.63
$1,060.08 Insertion
49440
Insertion of gastrostomy tube, percutaneous,
under fluoroscopic guidance including contrast
injection(s), image documentation and report
Replacement
43760
Change of gastrostomy tube, percutaneous,
without imaging or endoscopic guidance
$106.99
0676
$195.12
$48.69
$500.50
49450
Replacement of gastrostomy or cecostomy
(or other colonic) tube, percutaneous, under
fluoroscopic guidance including contrast
injection(s), image documentation and report
$267.52
0121
$487.87
$69.45
$678.79 2015 Medicare Ambulatory Surgery Center Fee Schedule
2015 Medicare Hospital Outpatient Prospective Payment System (OPPS) Fee Schedule
6
2015 Medicare Physician Fee Schedule
4
5
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
2015 physician fees for your local area can be found at the following CMS links:
http://www.cms.hhs.gov/apps/pfslookup/02_PFSearch.asp
or
http://www.cms.hhs.gov/PhysicianFeeSched/PFSNPAF/list.asp#TopOfPage
Current Procedural Terminology © 2014 American Medical Association.
All Rights Reserved. Disclaimer: The information provided herein reflects Cook’s understanding of the procedure(s) and/or device(s) from sources which may include, but are not limited to, the CPT,
ICD-9 and MS-DRG coding systems; Medicare payment systems; commercially available coding guides; professional societies; and research conducted by independent coding and reimbursement
consultants. This information should not be construed as authoritative. The entity billing Medicare and/or third party payers is solely responsible for the accuracy of the codes assigned to the services
and items in the medical record. Cook does not, and should not, have access to medical records, and therefore cannot recommend codes for specific cases. When making coding decisions, we encourage you to seek input from the AMA, AHA, relevant medical societies, CMS, your local Medicare Administrative Contractor and other health plans to which you submit claims. Cook does not promote
the off-label use of its devices.
© COOK 2015 RG_IR_EGFT_RE_201501
Effective January 1, 2015 - March 31, 2015