PEG Tube Placement
43246
Dysphagia requiring enteral nutrition access / neurologic impairment with inability to maintain oral intake / head and neck cancer / prolonged ventilator dependence
Same
Percutaneous endoscopic gastrostomy (PEG) tube placement
[Attending name], MD/DO
[Resident/PA name]
Monitored anesthesia care (MAC) with local anesthesia / general endotracheal
The patient is a [age]-year-old [male/female] with [indication: dysphagia/neurologic injury/head-neck cancer/prolonged intubation] requiring long-term enteral nutrition access. The patient is unable to maintain adequate oral intake to meet nutritional needs. The risks, benefits, and alternatives (including nasogastric tube, surgical gastrostomy, parenteral nutrition) were discussed with the patient [and/or healthcare proxy], and informed consent was obtained.
Upper endoscopy demonstrated [normal gastric mucosa / gastritis / prior gastric changes]. Transillumination of the left upper quadrant was [clearly visible / adequate]. Finger indentation of the gastric wall was [clearly identified endoscopically]. No contraindications to PEG placement were identified [such as prior gastric surgery / intervening organs].
The patient was brought to the procedure suite/operating room and placed supine. [MAC anesthesia / general endotracheal anesthesia] was administered. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics (including [cefazolin]).
An upper endoscope was introduced orally and advanced to the stomach under direct visualization. The esophagus, gastroesophageal junction, stomach, and duodenum were inspected — [no acute mucosal abnormalities were identified / findings as noted above]. The stomach was insufflated with air to achieve adequate distension.
The endoscope was positioned in the antrum/body of the stomach and the light source was directed anteriorly toward the abdominal wall. A site in the left upper quadrant was identified by clear transillumination and one-to-one finger indentation. [No intervening organs were identified.]
The selected site on the abdominal wall was prepped and draped in sterile fashion. Local anesthesia with [1% lidocaine with epinephrine] was infiltrated into the skin and subcutaneous tissue. A [5-mm] skin incision was made. The 18-gauge needle-cannula was advanced through the abdominal wall into the stomach under direct endoscopic visualization — placement within the stomach was confirmed. A looped guidewire/snare wire was advanced through the cannula and grasped with the endoscopic snare.
The endoscope and guidewire were withdrawn together through the mouth. The PEG tube [___-Fr] was attached to the guidewire and pulled retrograde through the mouth, esophagus, and stomach, and out through the abdominal wall using the [pull/push] technique. The internal bumper was seated against the gastric mucosa under endoscopic visualization — the bumper was [snug without excessive tension / with adequate slack allowing ___ mm of movement].
The external fixator was placed on the tube at the skin level. The tube was confirmed to be [20-24 Fr]. Tube placement was confirmed by [injection of air under endoscopic visualization with bubble formation seen in the stomach / successful aspiration of gastric contents]. The external bolster was secured. The tube was marked at the skin exit level.
The endoscope was removed. The patient tolerated the procedure without immediate complications. Tube feeds may begin [4-6 hours after/next day] per physician preference.
None
None
Minimal (less than 5 mL)
Percutaneous gastrostomy tube in place
The patient tolerated the procedure well and was taken to the recovery area in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Percutaneous endoscopic gastrostomy (PEG) tube placement
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: MAC with local anesthesia
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** requiring long-term enteral access. Informed consent obtained.
FINDINGS: Stomach normal. Transillumination and finger indentation confirmed LUQ site. No intervening organs.
DESCRIPTION OF PROCEDURE:
Supine. MAC + local. Surgical timeout per protocol.
Upper endoscopy — esophagus, stomach, duodenum normal. Stomach insufflated. LUQ site confirmed by transillumination and finger indentation. Skin incision. 18G needle-cannula into stomach under direct visualization. Guidewire placed and grasped endoscopically. PEG tube pulled retrograde through mouth, esophagus, stomach, and abdominal wall. Internal bumper seated under endoscopic visualization — snug without tension. External bolster placed. *** Fr tube confirmed. Placement confirmed by air injection/aspiration.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: PEG tube in place
DISPOSITION: The patient tolerated the procedure well and was returned to the recovery area in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Surgical Gastrostomy (Open/Laparoscopic)
A surgical gastrostomy was performed given [prior gastrectomy / morbid obesity / head and neck mass precluding endoscopic approach / esophageal obstruction]. [Laparoscopic: Two trocars were placed. The anterior gastric wall was identified.] [Open: A small left upper quadrant incision was made.] The anterior gastric wall was secured with two [3-0 Vicryl] purse-string sutures concentrically. A [20-Fr Foley / Stamm gastrostomy tube] was introduced into the stomach through a small gastrotomy. The purse-strings were cinched and tied around the tube. The stomach was tacked to the anterior abdominal wall with [2-0 Prolene] sutures in four quadrants.
PEG-J Tube (Jejunal Extension)
Given aspiration risk / gastroparesis, a PEG-J tube was placed with a jejunal extension. The PEG was placed as described. A jejunal extension tube was passed through the PEG tube into the stomach and advanced endoscopically into the post-pyloric position (third portion of duodenum / proximal jejunum) using a grasping forceps. Fluoroscopic confirmation of jejunal position was obtained. The jejunal port is for feeding; the gastric port is for venting.
Charting Tips
- Document transillumination AND finger indentation — both confirmations are required. Absent one or both is associated with inadvertent placement through colon (buried bumper/colocutaneous fistula), which is a rare but serious complication.
- Document the internal bumper position — state that the bumper was visualized endoscopically and was snug against the gastric mucosa without excessive tension. Excessive tension causes buried bumper syndrome; too loose causes leakage.
- Document when tube feeds may begin — this is a clinical order but its absence in the procedure note leads to confusion, especially for overnight coverage providers who need to know if the tube is safe to use immediately.
Billing Tips
- Bill 43246 for EGD with percutaneous gastrostomy tube placement (3.47 wRVU, 0-day global). Use for standard PEG placement by the pull or push technique.
- 0-day global period: PEG tube care, site checks, and routine follow-up are not bundled — a separate E/M can be billed if a significant evaluation is documented. Tube replacement through an established tract uses 43762 or 43763.
- If the PEG is placed in the OR under general anesthesia (e.g., for airway protection), the anesthesia and OR facility fees are separate. The procedure code remains 43246 regardless of setting.
- Fluoroscopic confirmation of PEG position is included in 43246 — do not separately bill fluoroscopy. External bumper position and internal bumper at the gastric wall should be documented to confirm correct placement depth.
- For surgical gastrostomy (open or laparoscopic, without endoscopy), use 43830 (open, 5.43 wRVU) or 43831 (neonatal). These are distinct from 43246 and used when endoscopic access is not feasible.