Enteral feeding or tube feeding is used for patients who have a functioning gastrointestinal tract but are unable to take any food or sufficient food orally. Clinicians frequently rely on enteral nutritional support in the management of neurological disorders affecting swallowing, head and neck malignancy, and oesophago-gastric diseases. Medical billing and coding outsourcing can help providers submit accurate claims for the services and items supplied.
Indications for Feeding Tube Placement
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Feeding tubes are generally placed therapeutically prior to treatment (or for palliative nutritional support if no treatment is indicated) if on diagnosis a patient has nutritional problems related either to the condition itself (e.g., dysphagia, or cachexia in cancer patients) or due to long-standing health behaviors such as poor dietary intake/heavy alcohol consumption, or in response to already existing nutritional problems. Feeding tubes may be also placed in response nutritional problems developed during or after treatment.
Enteral Feeding Techniques
In tube feeding, a special liquid food mixture containing protein, carbohydrates (sugar), fats, vitamins and minerals is delivered through a tube directly into the stomach, duodenum or jejunum. A nasogastric or nasoenteral feeding tube is placed through the nose into the stomach or bowel. If the tube is placed directly through the skin into the stomach or bowel, it is called a gastrostomy or jejunostomy. The G-J (gastromy-jejunostomy) tube is used in patients (typically children) who are unable to tolerate feeding of food directly into the stomach. A document from Ashford and St. Peters Hospitals lists the different types of G-tubes used in tube feeding as follows:
- Nasogastric tubes (NG): Typically used for short-term feeding, these are polyurethane tubes passed via the nose to the stomach. Options available include fine bore nasogastric tubes and NPSA compliant, wide bore (Ryles) tubes.
- Nasoduodenal/nasojejunal tubes: (ND/NJ) or post-pyloric tubes are placed via the nose to the duodenum or jejunum. Nasojejunal tubes may be placed at bedside, during surgery, endoscopically or radiologically.
- Gastrostomy tube (G-tube): A gastrostomy tube enters the stomach via a surgical incision in the abdominal wall. They are usually placed for longer term feeding.
- Percutaneous endoscopic gastrostomy (PEG): This gastrostomy tube is placed endoscopically under sedation.
- Radiologically inserted gastrostomies (RIG): Placed radiologically, RIG tubes require placement of a fine bore nasogastric tube prior to placement.
- Surgical gastrostomy: This tube is placed in the operating theatre, usually as part of another procedure.
- Balloon gastrostomy/low profile gastrostomy (button): These are radiologically inserted via a fully formed PEG or RIG stoma tract. They last 3-9 months although the balloon volume must be checked weekly.
- Jejunostomy tube: This specially designed feeding tube inserted into the jejunum during the abdominal phase of laparotomy for post pyloric feeding.
- Percutaneous endoscopic gastrostomy tube with jejunal extension (PEG-J): In PEG-J, a specially designed jejunal tube is passed through a PEG, past the pylorus into the jejunum.
- Endoscopic percutaneous jejunostomy (PEJ): This involves placing a tube endoscopically directlyinto the jejunum.
- Orogastric tube: This NPSA compliant wide bore tube is placed into the stomach via the mouth. A very short term measure, it is used in patients with a suspected or confirmed fractured base of skull or nasal trauma.
Reimbursement for Enteral Tube Placement
Reimbursement for gastrostomy tube placement depends on reporting the appropriate ICD-10 and CPT codes. Here are the relevant codes for 2018:
ICD-10 Codes for Gastrostomy Tube Placement
K21.0 – Gastro-esophageal reflux disease with esophagitis K20.9 – Esophagitis, unspecified K20.8 – Other esophagitis K22.10 – Ulcer of esophagus without bleeding K22.11 – Ulcer of esophagus with bleeding K22.2 – Esophageal ebstruction K22.3 – Perforation of esophagus K22.4 – Dyskinesia of esophagus K22.5 – Diverticulum of esophagus, acquired K22.6 – Gastro esophageal laceration hemorrhage syndrome K21.9 – Gastro-esophageal reflux disease without esophagitis K22.8 – Other specified diseases of esophagus K22.8 – Other specified diseases of esophagus J86.0 – Pyothorax with fistula K22.70 – Barrett’s esophagus without dysplasia K22.8 – Other specified diseases of esophagus K30 – Functional dyspepsia R13.10 – Dysphagia, unspecified R13.11 – Dysphagia, oral phase R13.12 – Dysphagia, oropharyngeal phase R13.13 – Dysphagia, pharyngeal phase R13.14 – Dysphagia, pharyngoesophageal phase R13.19 – Other dysphagia
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CPT Codes for Gastrostomy Tube Placement
Gastrostomy Tube Initial Placement
43246 Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube
49440 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidanceincluding contrast injection(s), image documentation and report
Gastrostomy Tube Replacement/Reposition
43760 Change of gastrostomy tube, percutaneous, without imaging or endoscopicguidance
43761 Repositioning of a nasal- or oro-gastric feeding tube, through the duodenum for enteric nutrition
49450 Replacement of gastrostomy or cecostomy (or other colonic) tube,percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
Jejunostomy Tube
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44373 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube
49440 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
49446 Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
49452 Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
Other Procedures
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
Feeding Tube Placement — Decision-making and Documentation
The decision related to adult nasogastric feeding tube insertion and management should be made by the physician responsible for the patient’s care. For complex, vulnerable patients, the decision-making should involve the multidisciplinary team. The decision should be made in the patient’s best interests, based on a careful assessment of the risks and benefits. The patient’s previously expressed wishes, an Advanced Care Plan, family involvement or an independent advocate should be given due consideration.
Medical coding outsourcing can ensure error-free reporting of feeding tube placement based on clinical documentation. The documentation should communicate critical information about the patient’s diagnosis, treatment, progress, and discharge status to other providers and also provide the information needed to justify services in the event of an audit by the payer. If information in the documentation is insufficient or does not support the billing codes, claims may be denied.
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