November 21, 2016

ICD-10 Coding: The Medical Necessity of Nasogastric Feeding Tubes

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The insertion of nasogastric (NG) tubes is a common practice in most hospitals. As more facilities begin to capture and code this procedure, correct ICD-10-PCS code assignment is necessary. This article explores key details associated with coding the insertion of nasogastric tubes in ICD-10.

Common Procedure for Many Patients

NG intubation is medically necessary for a variety of clinical situations, including:

  • Patients who can’t eat or swallow
  • Cases of neck or facial injuries
  • When mechanical ventilation is required or the patient is comatose
  • To relieve pressure on intestinal obstruction or blockage
  • To drain contents from the stomach or obtain a sample by applying suction to the NG tube
  • To deliver treatments such as administration of activated charcoal to absorb a harmful substance
  • And many others
For inpatients, the NG tube (NGT) is generally used to aspirate stomach contents or administer nourishment and medicine to people who cannot ingest anything by mouth. A Dobhoff tube is a small-bore, flexible tube that typically has an inside diameter of about 0.15 inches (4 mm) that is inserted into the stomach by way of the nasal passage. Use of this particular type of NG tube is considered a best practice. Following insertion, correct placement is confirmed by X-ray.

Depending on the practices of a medical facility, a Dobhoff tube can be inserted at a patient’s bedside by nursing staff or a physician. Because the tube’s position should be confirmed by X-ray, the tube can also be inserted by fluoroscopy; this is made simpler since Dobhoff tubes come with a radiopaque stripe, making them easily visible in X-rays.

When an NG tube is used for nutrition alone, it either runs continuously, 16 hours on and eight hours off, or by bolus feedings, meaning feeding is delivered en masse at one time. Bolus feedings are tantamount to eating meals three to five times a day.

A Look at the Codes

In ICD-9-CM, if the NGT was used for feeding only, it was captured with ICD-9-CM code 96.6, enteral infusion of concentrated nutritional substances. In ICD-10, however, proper coding of NG feeding tube insertion requires coders to consider a few more details.

In the Coding Clinic edition published during the second quarter of 2015, on page 29, a question was asked about the insertion of a nasogastric tube for drainage and feeding. The subsequent response provides correct coding guidance.

Question:

A nasogastric (NG) tube was inserted for drainage. The next day, tube feedings were ordered using the existing NG tube. What is the correct root operation(s) for the insertion of a single NG tube used for drainage and feeding?

Answer:

The placement of a nasogastric tube does not need to be coded in the inpatient setting. However, for facilities that wish to collect this information, assign the following ICD-10-PCS codes:

0D9670Z, Drainage of stomach with drainage device, via natural or artificial opening 

3E0G76Z, Introduction of nutritional substance into upper GI, via natural or artificial opening

Decide Before You Code

Consider how you were instructed before the implementation of ICD-10-CM/PCS. Most ICD-10 training programs mandated that unless otherwise instructed, coders should continue to employ the same coding practices used in ICD-9-CM. This means if a facility didn’t code a procedure in ICD-9, they shouldn’t capture it in ICD-10-PCS. In ICD-9-CM, we only captured 96.6, enteral infusion of concentrated nutritional substances for NGT feedings, and no code was captured for the actual insertion of the tube. 

Since ICD-10 represents a different coding nomenclature, coding teams should take the time to reconsider how they will manage NGT feeding procedures in ICD-10-PCS. For organizations that decide to capture inpatient NGT feedings in ICD-10-PCS, the following guidelines must be applied. 

Consider the Objective

The ICD-10-PCS reference manual states that “the objective of an insertion is putting in a non-biological device.” Under the explanation, it reads that “the root operation insertion represents those procedures where the sole objective is to put in a device without doing anything else to a body part.”

The ICD-10-PCS reference manual defines introduction as “putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance, except blood or blood products,” and gives the example of “infusion of total parenteral nutrition via central venous catheter: 3E0436Z.”

Therefore, if the sole objective of inserting the NGT (Dobhoff tube) is for feeding purposes, then code only 3E0G36Z, Introduction of nutritional substance into upper GI, percutaneous approach.

Beyond Nutrition

In intubated patients, an NG or OG (orogastric) tube is often in place and set to low-intermittent suction (LIS). Often these patients will have an NJ (nasojejunal) instead of a nasogastric tube. This is done so the feedings/medications are placed beyond the pyloric sphincter and into the small intestine, decreasing the risk that the substances will migrate up into the esophagus and end up causing aspiration of the contents into the trachea or lungs.

The LIS suction that would be done for these situations (through an NJ/OJ) is backup protection. If anything sneaks back up through the pylorus, it can be suctioned out into a canister.

Also, the stomach makes a lot of its own secretions that need to be suctioned out in patients whose stomachs are not performing normal digestive functions. Buildup of normal stomach secretions can lead to an erosive event in the stomach or esophagus (or aspiration of stomach acid into the trachea or lungs).

Additionally, all patients who are intubated have to have the head of the bed elevated to 30 degrees or greater to further prevent aspiration. This is a big quality measure for hospitals.

Two other instances in which NG or OJ tubes are indicated include emergency room patients with overdoses or any other stomach pathology requiring evacuation. For overdoses, the activated charcoal mentioned previously in this article would be administered first, via the tube. Other pathology causing the stomach to be filled with bile, blood, secretions, etc. might indicate evacuation with an NG/OG tube.

For these patients (NG placed for evacuation of stomach contents) the code for drainage of stomach with drainage device via natural or artificial opening would be 0D9670Z. 
Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Kim Carr brings more than 30 years of health information and clinical documentation improvement management experience and expertise to her role as Director of Clinical Documentation, where she provides oversight for auditing and documentation improvement for HRS clients. Prior to joining HRS, Kim worked as a consultant implementing CDI programs in varied environments such as level-one trauma centers, small community hospitals and all levels in between.

Before joining the consultant arena, Kim served as Manager of CDI in an academic level-one trauma center. She was responsible for education and training for physicians and clinical documentation specialists. Over the past 30 years, Kim has held several HIM positions; including HIM Coding Educator, Quality Assurance/Utilization Management Coordinator, DRG Coding Coordinator and Coding Manager. Kim holds a degree in Health Information Management and is a member of AHIMA, THIMA, ACDIS and AAPC.