How To Use CPT Code 49465

CPT 49465 describes the administration of contrast material through a percutaneous approach to evaluate existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube. 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 49465?

CPT 49465 is used to describe the injection of contrast material through a feeding or drainage tube in the abdominal wall to visualize the contents of the tube and identify any blockages. This procedure includes both the creation of images and the preparation of a report.

2. Official Description

The official description of CPT code 49465 is: ‘Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report.’

3. Procedure

1. The provider administers contrast material through a preexisting tube in the abdominal wall.
2. Using fluoroscopic guidance, the provider assesses the movement of the contrast material to identify any obstructions in the tube.
3. The provider creates images to document the findings and prepares a report.

4. Qualifying circumstances

CPT 49465 is performed when there is a need to evaluate the contents of a preexisting gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy tube. The procedure is typically performed through a percutaneous approach. The use of contrast material allows for better visualization of the tube and identification of any blockages.

5. When to use CPT code 49465

CPT code 49465 should be used when contrast material is injected through a preexisting tube in the abdominal wall to evaluate its contents and identify any obstructions. It is important to note that CPT code 49465 should not be reported in conjunction with codes 49450-49460, as these codes represent different procedures.

6. Documentation requirements

To support a claim for CPT code 49465, the provider must document the following information:

• The reason for the procedure and the need to evaluate the tube
• The type of tube being evaluated (gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, cecostomy, or other colonic tube)
• The use of contrast material and the amount administered
• The date of the procedure
• The images created during the procedure
• A detailed report of the findings

7. Billing guidelines

When billing for CPT code 49465, ensure that the procedure is performed through a percutaneous approach and includes the administration of contrast material, image documentation, and report preparation. It is important to note that CPT code 49465 should not be reported in conjunction with codes 49450-49460, as these codes represent different procedures. Additionally, if an obstruction is found during the procedure and subsequently removed, CPT code 49460 should be reported for the removal under fluoroscopic guidance.

8. Historical information

CPT code 49465 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 provider injects contrast material through a gastrostomy tube to evaluate its contents and identify any obstructions.
2. Using fluoroscopic guidance, a provider administers contrast material through a jejunostomy tube to visualize the tube and locate any blockages.
3. A provider performs a contrast injection through a cecostomy tube to assess the movement of the contrast material and identify any obstructions.
4. Using a percutaneous approach, a provider injects contrast material through a gastro-jejunostomy tube to evaluate its contents and identify any blockages.
5. A provider administers contrast material through a duodenostomy tube to visualize the tube and locate any obstructions.
6. Using fluoroscopic guidance, a provider performs a contrast injection through a colonic tube to assess the movement of the contrast material and identify any obstructions.
7. A provider injects contrast material through a gastrostomy tube to evaluate its contents and identify any obstructions.
8. Using fluoroscopic guidance, a provider administers contrast material through a jejunostomy tube to visualize the tube and locate any blockages.
9. A provider performs a contrast injection through a cecostomy tube to assess the movement of the contrast material and identify any obstructions.
10. Using a percutaneous approach, a provider injects contrast material through a gastro-jejunostomy tube to evaluate its contents and identify any blockages.