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The newest on PEGJ: Understand what a percutaneous endoscopic gastrojejunostomy is, and what it isn’t

Association of Clinical Documentation Improvement Specialists, May 5, 2008

by Robert S. Gold, MD

We learn something new every day. For the past several years, I’ve been complaining about advice in a particular Coding Clinic—both in the index and in the world of practical, day-to-day coding. Below is a recent letter I wrote to CMS.

It has been my contention that Coding Clinic, first quarter 2001, pp. 16–17, incorrectly defined an interventional procedure—percutaneous endoscopic gastrojejunostomy (PEGJ)—and assigned it to ICD-9-CM procedure code 44.39. Eventually, a specific code for that procedure came into being and was further elucidated in Coding Clinic, October 2001, as ICD-9-CM procedure code 44.32. It is identified as an operating room (OR) procedure, and coders assigned this new code based on old definitions. As a result, hospitals have received millions of dollars for a procedure that the gurus (i.e., CMS, National Centers for Health Statistics, and their physician advisors) incorrectly defined. However, these same gurus assigned the procedure a status that is based on the correct definitions—which we don’t have.

To reiterate, in 2001, a question presented in Coding Clinic concerned the correct code assignment for PEGJ. However, Coding Clinic provided an answer applicable to a percutaneous endoscopic jejunostomy (PEJ). Coding Clinic instructed coders to report ICD-9 procedure code 44.39. This is an OR procedure code, as is the code for a percutaneous endoscopic gastrostomy (PEG) tube insertion. The Coding Clinic description provided in October 2001, when 44.32 was developed, involved inserting a smaller tube through an existing PEG tube and endoscopically carrying the end of that tube past the duodenum and into the jejunum. This is the conversion of a percutaneous, endoscopically assisted feeding gastrostomy to a percutaneous, endoscopically redirected feeding jejunostomy.

The objective of the procedure is to feed a patient adequate nutrition at a point in the bowel past the duodenum, lowering the incidence of aspiration. The advice Coding Clinic provided was correct, and the procedure described was correct, but it was not a gastrojejunostomy. It didn’t belong with gastrojejunostomies. At the time, a PEGJ had never been performed.

In order to code a PEG insertion versus a PEJ, ensure that your coding staff is familiar with the following codes:

  • 43.11: This is the code for PEG. It remains a non-OR procedure.
  • 46.32: This is the code for PEJ. It remains a non-OR procedure.

Over time, medicine advanced and innovations occurred. However, the coding rules misconstrued the issue. We have paid enormous amounts of money for the wrong reasons.

Code 44.32 was developed for a new procedure, but was defined as the old procedure. Physicians rarely perform the new procedure, and it carries a relatively high risk, whereas physicians frequently perform the old procedure, and it carries virtually no risk. As it is defined, code 44.32 is bogus.

Hospital coding departments have been misled by the coding rules. They have also been delighted to increase the case-mix index of their neurologic and oncologic service lines by incorrectly assigning DRG 468. It was the conversion of a non-OR procedure to another non-OR procedure that somehow gained OR status. This happened despite the fact that this procedure requires less time and effort than either the PEG or PEJ initial placement in the same location.

A true PEGJ consists of:

  • Passing an upper-gastrointestinal scope into the stomach
  • Cutting through the wall of the stomach with an electric or laser knife at a dependent portion of the stomach
  • Fishing the scope into the free abdominal cavity with forceps
  • Finding a piece of small intestine and dragging it up into the stomach
  • Opening that piece and then anastomosing the cut edge of the small intestine with the cut edge of the stomach

If you look at the other 44.3 series of codes, you’ll see that they consist of the attachment of the stomach to the small intestine, whether for obstruction or gastric bypass. This is a gastrojejunostomy. All of the 44.3 codes are gastrojejunostomies except one: 44.32. As stated above, 44.32 is the conversion of a PEG to a PEJ. It is wrong to call it a gastrojejunostomy. Conversion of a PEG to a PEJ should not be included in the 44.3 series at all.

A procedure called a gastrojejunostomy does exist. It’s likely that coders will assign the correct code to this procedure, unless the coders read the Coding Clinic instructions. In that case, they will be confused, because these instructions apply to a totally different procedure (i.e., endoscopic conversion of a feeding gastrostomy to a feeding jejunostomy through the old PEG site). TheCoding Clinic instructions are for a non-OR procedure that groups to an OR procedure, and this is incorrect.

Note that CPT code 49446 defines the same operation using the term “gastrojejunostomy tube.” However, there is no such thing as a gastrojejunostomy tube. It’s a trans-gastrostomal feeding jejunostomy.

I received notification from CMS that, in light of the evidence presented to them regarding the two procedures that had the same name (PEGJ), they worked out a revision of the index as follows:

44.32 Percutaneous [endoscopic] gastrojejunostomy

  • Delete inclusion term: Endoscopic conversion of gastrostomy to jejunostomy
  • Add inclusion term: Bypass:
  • Add inclusion term: gastroduodenostomy
  • Revise inclusion term: PEG PEGJJ

  • Add exclusion term: Excludes: percutaneous (endoscopic) feeding jejunostomy (46.32)

    Conversion

  • Revise subterm: gastrostomy to jejunostomy (endoscopic) 44.32
  • Add subterm: for feeding tube placement 46.32

    Gastrojejunostomy (bypass) 44.39

    with partial gastrectomy 43.7

    laparoscopic 44.38

    percutaneous (endoscopic) 44.32

  • Add subterm: for bypass 44.32
  • Add subterm: for feeding tube placement 46.32

Editor’s note: Dr. Gold founded DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician programs in clinical documentation improvement. The goals are data accuracy, profile management, and compliance, either in the inpatient or outpatient arenas. He can be reached by phone at 770/216-9691 or by e-mail at DCBAInc@cs.com.

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