CPT® Code 0647T

Official Description

Insertion of gastrostomy tube, percutaneous, with magnetic gastropexy, under ultrasound guidance, image documentation and report

Common Language Description

The procedure described by CPT® Code 0647T involves the insertion of a gastrostomy tube using a percutaneous approach, specifically employing magnetic gastropexy under ultrasound guidance. This innovative technique, known as percutaneous ultrasound gastrostomy (PUG), is designed to facilitate the placement of a gastrostomy tube at the bedside without the need for fluoroscopy or endoscopy. The procedure utilizes a specialized device called the point-of-care ultrasound magnetically aligned gastrostomy (PUMA-G) device, which includes an orogastric catheter equipped with a balloon tip that contains a magnetic bar. An external hand-held magnet is also utilized during the procedure. The process begins with the insertion of the orogastric tube through the mouth or nose into the stomach. The external magnet is then positioned over the balloon's location within the stomach, allowing the physician to maneuver the balloon to the desired site while simultaneously using ultrasound imaging for guidance. The magnets generate a static compressive force that effectively pushes the stomach against the abdominal wall, facilitating the creation of a clear pathway for the gastrostomy tube. Ultrasound imaging is employed once more to visualize the intended gastrostomy tract, which extends from the skin to the stomach. Following this, a cutaneous puncture is made, and a guidewire is inserted through the puncture site into the stomach. Finally, the gastrostomy tube is carefully placed over the guidewire, ensuring it is positioned correctly within the stomach. This procedure is particularly beneficial for patients requiring long-term nutritional support, as it allows for a minimally invasive approach to gastrostomy tube placement.

1. Indications

The insertion of a gastrostomy tube via the percutaneous ultrasound technique is indicated for patients who require long-term enteral feeding due to various medical conditions. The following conditions may warrant this procedure:

Neurological Disorders Patients with conditions such as stroke, cerebral palsy, or neurodegenerative diseases that impair swallowing and necessitate nutritional support.
Head and Neck Cancers Individuals undergoing treatment for cancers in the head and neck region that affect the ability to eat or swallow.
Chronic Illnesses Patients with chronic illnesses, such as advanced dementia or severe anorexia, where oral intake is insufficient to meet nutritional needs.
Gastrointestinal Disorders Conditions that impair the gastrointestinal tract's ability to absorb nutrients, such as Crohn's disease or severe pancreatitis.

2. Procedure

The procedure for the insertion of a gastrostomy tube using the percutaneous ultrasound technique involves several critical steps:

Step 1: Preparation The patient is positioned appropriately, and the area of the abdomen where the gastrostomy tube will be inserted is cleaned and sterilized to minimize the risk of infection. The physician ensures that all necessary equipment, including the PUMA-G device and ultrasound machine, is readily available.
Step 2: Orogastric Tube Insertion An orogastric tube is inserted through the patient's mouth or nose and advanced down into the stomach. This tube serves as a guide for the subsequent steps of the procedure.
Step 3: Magnetic Alignment The external hand-held magnet is positioned over the balloon tip of the orogastric tube, which is located internally in the stomach. The physician uses the magnet to maneuver the balloon to the desired location within the stomach while utilizing ultrasound imaging for real-time guidance.
Step 4: Visualization of the Gastrostomy Tract Ultrasound imaging is employed to visualize the pathway from the skin to the stomach, allowing the physician to determine the optimal site for the gastrostomy tube insertion.
Step 5: Puncture and Guidewire Placement A cutaneous puncture is made at the identified site, and a guidewire is carefully inserted through the puncture site and advanced into the stomach, providing a pathway for the gastrostomy tube.
Step 6: Gastrostomy Tube Insertion The gastrostomy tube is then placed over the guidewire and advanced into the stomach, ensuring it is positioned correctly for effective enteral feeding.

3. Post-Procedure

After the insertion of the gastrostomy tube, the patient is monitored for any immediate complications, such as bleeding or infection at the insertion site. Instructions for care of the gastrostomy tube and the surrounding skin are provided to the patient or caregiver. Follow-up appointments are typically scheduled to assess the placement of the tube, ensure proper function, and address any concerns regarding feeding and nutrition. Patients may also receive education on how to manage the gastrostomy tube, including cleaning and maintenance, to prevent complications and ensure optimal use.

Short Descr	INSJ GTUBE PERQ MAG GASTRPXY
Medium Descr	INSJ GASTROSTOMY TUBE PERQ W/MAGNETIC GASTROPEXY
Long Descr	Insertion of gastrostomy tube, percutaneous, with magnetic gastropexy, under ultrasound guidance, image documentation and report
Status Code	Carriers Price the Code
Global Days	YYY - Carrier Determines Whether Global Concept Applies
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator	Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight.
Berenson-Eggers TOS (BETOS)	none
MUE	1

51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52	Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53	Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
GC	This service has been performed in part by a resident under the direction of a teaching physician