How To Use CPT Code 49441

CPT 49441 describes the percutaneous insertion of a jejunostomy or duodenostomy tube under fluoroscopic guidance, including contrast injection(s), image documentation, and report. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 49441?

CPT 49441 can be used to describe the percutaneous insertion of a jejunostomy or duodenostomy tube under fluoroscopic guidance. This procedure is performed by a healthcare provider to feed a patient who is at a higher risk of aspiration and has undergone gastrectomy to remove the stomach. The provider inserts the tube through the skin using fluoroscopic guidance to ensure accurate placement.

2. Official Description

The official description of CPT code 49441 is: ‘Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation, and report.’

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. Using fluoroscopic guidance, the provider punctures the abdominal wall and inserts a needle.
3. A guide wire is passed through the needle, and the needle is removed.
4. A dilator is placed to allow for the serial dilatation of the tract.
5. The jejunostomy or duodenostomy tube is inserted into the small intestine and secured in place with stitches.
6. After securing the tube, the provider removes all instruments and applies sterile dressings.

4. Qualifying circumstances

CPT 49441 is performed on patients who have undergone gastrectomy and are at a higher risk of aspiration. The procedure involves the percutaneous insertion of a jejunostomy or duodenostomy tube under fluoroscopic guidance. This code should only be used when the procedure is performed by a qualified healthcare provider.

5. When to use CPT code 49441

CPT code 49441 should be used when a healthcare provider performs the percutaneous insertion of a jejunostomy or duodenostomy tube under fluoroscopic guidance. This code should not be used for other types of tube insertions or procedures. It is important to accurately document the procedure and ensure that it meets the criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 49441, the healthcare provider must document the following information:

• Patient’s medical history and indication for the procedure
• Details of the fluoroscopic guidance and contrast injection(s)
• Image documentation of the procedure
• A comprehensive report outlining the steps taken during the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 49441, ensure that the procedure meets the criteria outlined in the code description. The provider should use fluoroscopic guidance and perform contrast injection(s) as necessary. It is important to accurately document the procedure and provide a comprehensive report. CPT code 49441 should not be reported with other codes unless additional procedures were performed. It is recommended to review the specific guidelines provided by the payer to ensure accurate billing.

8. Historical information

CPT 49441 was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs a percutaneous insertion of a jejunostomy tube under fluoroscopic guidance for a patient who has undergone gastrectomy.
2. Using fluoroscopic guidance, a provider inserts a duodenostomy tube percutaneously to provide nutrition to a patient at risk of aspiration.
3. A patient who has undergone gastrectomy receives a percutaneous jejunostomy tube insertion under fluoroscopic guidance to ensure proper feeding.
4. A healthcare provider performs a percutaneous insertion of a duodenostomy tube under fluoroscopic guidance for a patient who is unable to tolerate oral intake.
5. Using fluoroscopic guidance, a provider inserts a jejunostomy tube percutaneously to provide enteral nutrition to a patient with a high risk of aspiration.
6. A patient who has undergone gastrectomy receives a percutaneous duodenostomy tube insertion under fluoroscopic guidance to facilitate feeding.
7. A healthcare provider performs a percutaneous insertion of a jejunostomy tube under fluoroscopic guidance for a patient with impaired gastric function.
8. Using fluoroscopic guidance, a provider inserts a duodenostomy tube percutaneously to provide enteral nutrition to a patient with a compromised digestive system.
9. A patient who has undergone gastrectomy receives a percutaneous jejunostomy tube insertion under fluoroscopic guidance to ensure adequate nutrition.
10. A healthcare provider performs a percutaneous insertion of a duodenostomy tube under fluoroscopic guidance for a patient who requires enteral feeding.