Find comprehensive information on Percutaneous Endoscopic Gastrostomy (PEG) diagnosis, including clinical documentation requirements, medical coding guidelines (ICD-10, CPT), and healthcare best practices. Learn about PEG tube placement, aftercare, and potential complications. This resource offers valuable insights for physicians, nurses, and other healthcare professionals involved in PEG procedures and patient management.
Also known as
Percutaneous endoscopic gastrostomy
Creation of an opening into the stomach through the skin.
Other postprocedural disorders of digestive
Complications like infection or leakage after a PEG procedure.
Other complications of surgical procedures
General complications not specific to PEG placement.
Presence of percutaneous endoscopic gastrostomy
Indicates a patient has a PEG tube, for aftercare or other needs.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is PEG for feeding?
Yes
Any complications?
No
Reason for PEG?
When to use each related code
| Description |
|---|
| Percutaneous Endoscopic Gastrostomy |
| Gastrostomy, Open |
| Nasoenteric Tube Placement |
Coding PEG placement vs. PEG exchange or removal requires distinct CPT codes. Miscoding leads to claim denials and revenue loss.
Lack of specific diagnosis justifying PEG placement impacts medical necessity reviews and can trigger audits or denials. CDI crucial.
For complex PEG procedures, appropriate modifiers (e.g., for fluoroscopy) must be appended for accurate reimbursement and compliance.
Percutaneous endoscopic gastrostomy (PEG) tube placement was indicated due to the patient's inability to maintain adequate oral intake, resulting in documented malnutrition or risk thereof. Contributing factors include dysphagia, oropharyngeal dysphagia, stroke, head and neck cancer, neurological impairment, and aspiration pneumonia risk. The procedure was performed under conscious sedation or general anesthesia, guided by endoscopic visualization. The stomach was accessed percutaneously, and a PEG tube was inserted and secured. Post-procedure assessment confirmed proper placement and function of the PEG tube. The patient tolerated the procedure well, with no immediate complications noted, such as bleeding, infection, or peritonitis. A plan was initiated for PEG tube care, including regular flushing, site hygiene, and patient education on administration of enteral nutrition or medications via the PEG tube. Follow-up appointments were scheduled for monitoring of tube patency, nutritional status, and potential complications including granulation tissue formation or leakage. ICD-10 code assignment will reflect the underlying etiology for PEG tube placement, such as cerebral palsy, dementia, or head and neck neoplasm, along with appropriate CPT codes for the PEG procedure itself. Medical nutrition therapy consult was ordered to optimize enteral feeding regimen. Discharge planning included patient and caregiver education regarding PEG tube management, potential complications, and emergency contact information.