Question: How do I code when two gastroenterologists perform a percutaneous placement of a gastrostomy (PEG) tube (43246)? Some of our gastroenterologists use modifier -62, and others use modifier -80. What modifier should we use if one gastroenterologist performs the endoscopy and another makes the incision (both are partners in the same group practice)? What modifier should we use if a surgeon who is not affiliated with the gastroenterologists group practice makes the incision?
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Answer: When two physicians are involved in the placement of a PEG tube (43246 upper gastrointestinal endoscopy including esophagus stomach and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) the CPT manual indicates that modifier -62 (two surgeons) should be used to report the procedure says Pat Stout CMT CPC an independent gastroenterology coding consultant in Knoxville " Tenn.
Principals of CPT Coding " written and published by the American Medical Association states [w]hen a PEG tube is placed by two physicians each physician reports 43246 with the -62 modifier appended. Under Medicare payment rules " each physician will receive 62.5 percent of the allowed amount for the procedure when modifier -62 is attached.
Some payers" however require the use of modifier -80 (assistant surgeon) according to Stout especially when two gastroenterologists perform the placement. In this situation the gastroenterologist who performs the endoscopy should report 43246 " with no modifier attached; reimbursement will be 100 percent of the allowed amount for the procedure. The gastroenterologist who made the incision should report 43246 with modifier -80 attached; reimbursement will be 16 percent of the allowed amount for the procedure.
Some Medicare carriers use policies that are a hybrid of the two just mentioned. National Heritage Insurance Company (NHIC)" the Part B carrier for California recently issued coding instructions for PEG tube placements in its September 2000 Medicare Bulletin. According to its policy " only when two surgeons perform the procedure can modifier -62 be used. For all other two-physician placements whether its a gastroenterologist and a surgeon or two gastroenterologists 43246 with modifier -80 attached should be reported by the assistant (typically the surgeon who handles the preparation and treatment of the abdomen).
None of the policies reviewed made their coding requirements dependent upon whether the assisting physician was affiliated with the primary physician.
The California bulletin addresses another common coding problem that occurs with PEG tube placements: reporting of manual placement code 43750 (percutaneous placement of gastrostomy tube) in addition to 43246. Code 43750 should not be billed in addition to 43246 for one endoscopically directed PEG tube placement. The bulletin states" surgical CPT code 43750 will not be allowed in addition to 43246 " even when billed by different physicians. Medicare also prohibits the billing of surgical CPT code 43750 as an assistant or cosurgeon for Medicare patients.
Note: For more information on PEG tube placements" please see Method of Insertion or Removal Determines Amount of Payment for PEG Tube Procedures on page 49 of the July 2000 Gastroenterology Coding Alert.