CCSD code G4440 – Therapeutic OGD with PEG or PEJ insertion

Key takeaways

CCSD Code G4440 covers therapeutic OGD with PEG or PEJ insertion, so both tube positions bill under one code.

The OGD passage is integral to G4440, so it is never billed with G4410, G4430 or G6500 on the same episode.

Insurers generally expect pre-authorisation for G4440, so confirm each payer’s current rule before the list is booked.

A radiologically inserted gastrostomy (RIG) uses no endoscope and is never coded as G4440.

Pabau, the practice management platform we build, keeps consent, procedure notes and insurer claims in one patient record.

What is CCSD Code G4440?

CCSD Code G4440 is the Clinical Coding and Schedule Development (CCSD) code for therapeutic OGD with insertion of a percutaneous endoscopic gastrostomy or jejunostomy. UK private medical insurers all work from the CCSD code schedule. G4440 sits in Chapter 10, Endoscopic GIT Procedures, alongside diagnostic and other therapeutic OGD codes.

The official descriptor reads: Therapeutic oesophago-gastro-duodenoscopy (OGD) with insertion of percutaneous endoscopic gastrostomy/percutaneous endoscopic jejunostomy. That single descriptor covers both procedures. A PEG places the feeding tube into the stomach, while a PEJ places it into the jejunum. Both use an endoscope passed through the upper GI tract, so the CCSD schedule treats either one as a single episode under G4440.

However, the code applies only to endoscopically guided tube placement. Radiologically inserted gastrostomy (RIG), performed under fluoroscopic guidance by interventional radiology, is a separate procedure. Therefore, submitting G4440 for a RIG procedure is a miscoding error that insurers will identify on clinical review. A later operation to close a persistent gastrostomy tract is a separate episode too, billed under G3440 rather than G4440.

What the procedure involves: PEG and PEJ step by step

Both PEG and PEJ insertion follow a broadly similar endoscopic pathway. The stages matter for documentation. For example, insurers may request the operative report, and it needs to show an endoscopic approach to justify G4440 over a diagnostic code.

1. Patient preparation. The team obtains and documents informed consent. The patient fasts in line with standard endoscopic pre-procedure requirements. The team also writes a pre-procedure check note recording indication, ASA status, and any contraindications.
2. Sedation or general anaesthetic. The procedure can be performed under conscious sedation (midazolam with or without fentanyl) or general anaesthetic (GA). When a separate consultant anaesthetist provides GA or deep propofol sedation, the anaesthetist bills on their own. In contrast, the G4440 fee usually includes routine conscious sedation given by the endoscopist.
3. Endoscope passage. The gastroscope is passed through the oesophagus and stomach to the level of the proposed gastrostomy site. This OGD passage is integral to the procedure and is never a separate diagnostic episode.
4. Transillumination and site marking (PEG). Next, the endoscopist illuminates the gastric wall to identify a safe puncture site on the anterior abdominal wall, confirmed by a finger-indent technique.
5. Tube placement. For PEG, the Ponsky pull technique or introducer technique draws the tube through the abdominal wall. The endoscopist then seats the internal bumper against the gastric mucosa. For direct PEJ or PEG-J, however, the endoscopist advances the tube beyond the pylorus into the jejunum under endoscopic guidance.
6. Post-procedure check. Finally, the endoscopist confirms position endoscopically and secures the external fixator. A post-procedure check note documents tube position, any immediate complications, and initial care instructions for the nutrition team.

Clinical indications: when is G4440 appropriate?

Payers require documented medical necessity. According to NICE guideline CG32 on nutrition support in adults, gastrostomy feeding suits patients who need long-term enteral nutrition. It applies when oral intake is inadequate or unsafe. The most common private practice indications are:

• Neurological dysphagia. Motor neurone disease (MND/ALS) is one of the most frequent indications. PEG is often inserted early in the disease, before falling respiratory function raises the procedural risk. Post-stroke dysphagia and multiple sclerosis with severe swallowing impairment are further indications.
• Head and neck cancer. Patients undergoing radiotherapy for oral, pharyngeal, or laryngeal cancers often need preventive or reactive PEG placement to maintain nutritional status during and after treatment.
• Gastroparesis. When delayed gastric emptying makes gastric feeding impractical, a PEJ bypassing the stomach into the jejunum is preferred. Therefore, this is the main clinical driver for PEJ rather than PEG under G4440.
• Other causes of prolonged dysphagia or malnutrition. Oesophageal pathology, severe neurological injury, and certain oncological presentations may all justify long-term enteral access via G4440.

The British Society of Gastroenterology (BSG) has published guidelines for enteral feeding and PEG insertion, covering indications, contraindications and documentation standards. In addition, referencing BSG guidance in the referral letter strengthens the clinical justification when submitting to private insurers.

PEG vs PEJ: how G4440 applies to both procedures

G4440 covers both PEG and PEJ insertion because the parent procedure in each case is a therapeutic OGD. The two differ in the final tube position, while the code used to bill the episode stays the same. The table below therefore summarises the differences that matter for billing and clinical documentation.

G4440 vs related CCSD endoscopy codes: avoiding miscodings

Chapter 10 of the CCSD schedule contains several OGD codes that are easy to confuse with G4440. The biggest billing risk is unbundling, which means billing a diagnostic OGD code alongside G4440 on the same episode. The endoscope passage is integral to the therapeutic procedure, so a separate diagnostic scope on the same day is not billable. G4440 cannot be billed with G4410, G4430 or G6500 on the same episode, since each is a different OGD code. To help, the chart below matches what the operative report shows to the right code.

Next, the table below sets out how each related code differs from G4440.

PEG vs radiologically inserted gastrostomy: coding implications

Radiologically inserted gastrostomy uses fluoroscopic guidance rather than an endoscope. Also, the operator is usually an interventional radiologist rather than a gastroenterologist. G4440’s descriptor specifies “percutaneous endoscopic”, so the code does not apply to RIG procedures. A G4440 claim for a RIG draws a clinical query or denial once the insurer finds no endoscopy report.

Pre-authorisation requirements for CCSD Code G4440

Insurers generally expect pre-authorisation for G4440 before the procedure, so confirm each payer’s current rule. Requirements vary by insurer, but most requests cover the same core elements. These are the diagnosis, the clinical indication, and confirmation that the treating consultant has assessed the patient.

Consultants billing under Bupa CCSD codes should check the current pre-authorisation pathway on the Bupa provider portal, as requirements change. In addition, the table below lists the documents and contact routes for four main insurers. Confirm current requirements directly with each payer before proceeding.

Documentation requirements to support a G4440 claim

Incomplete documentation is a frequent reason G4440 claims are queried or denied. Insurers therefore expect a clear paper trail from clinical need through procedure to outcome. Digital consent and procedure forms also help confirm each document is on file before a claim is submitted. Gather the following documents before the claim is raised:

• Endoscopy report. Must state that an OGD was performed and name the technique (pull, push or introducer for PEG; endoscopic guidance for PEJ). It also confirms tube position, records any immediate findings, and carries the endoscopist’s name and the date.
• Pre-procedure consent. Signed informed consent documenting that risks, alternatives (including RIG and nasogastric feeding), and long-term implications were discussed.
• Referral or consultant letter. Should name the diagnosis and the clinical indication for enteral access, such as MND with progressive dysphagia. It should also confirm the procedure was planned as a therapeutic intervention.
• Dietitian or MDT involvement note. Bupa and several other payers ask for evidence that nutritional need has been formally assessed. A dietitian referral letter or MDT outcome note satisfies this requirement.
• Post-procedure check note. Documents tube position at the end of the procedure, immediate complications (or absence of them), and nursing or care handover instructions.
• Anaesthetic record. Required when a separate consultant anaesthetist was involved and an anaesthesia code is being billed alongside G4440.

Anaesthesia and sedation: separate billing alongside G4440

Whether anaesthesia can be billed separately alongside G4440 depends on who delivered it and how. The governing principle in the CCSD schedule is that the procedure fee includes routine conscious sedation given by the performing endoscopist. A separate anaesthesia code is right only when a consultant anaesthetist provided an independent professional service.

• Conscious sedation by the endoscopist (e.g. midazolam, fentanyl). G4440 bundles it in, so no separate anaesthesia code applies.
• Propofol sedation by an anaesthetist (TIVA or nurse-delivered propofol under anaesthetic supervision). Billed separately under the appropriate CCSD anaesthesia code. The endoscopist bills G4440; the anaesthetist bills their anaesthesia code independently.
• General anaesthetic. The anaesthetist bills separately, and the consultant’s G4440 claim is unaffected. Both claims may need pre-authorisation, so check whether the procedure authorisation extends to the anaesthetic component.

Bundling rules vary by insurer. For example, some payers include certain sedation services in the procedure fee regardless of who delivered them; others do not. So confirm the specific payer’s position before submitting a dual claim. Also, submitting an anaesthesia code without supporting documentation from the anaesthetist is a common audit finding.

Common reasons G4440 claims are rejected

G4440 claim rejections follow a clear pattern across private insurers. Each of the issues below has a direct fix that your team can build into the pre-submission workflow. In addition, running pre-submission checks in error-checking claims software cuts avoidable rejections.

• Missing pre-authorisation. The insurer expected authorisation and has no record of approving the procedure before it was performed. Fix: make pre-authorisation a mandatory step before booking the procedure list.
• Incomplete or missing endoscopy report. The insurer requests clinical notes and receives no operative report, or a report that does not mention the OGD passage. Fix: ensure every PEG/PEJ procedure generates a structured endoscopy report on the day.
• Wrong code submitted. A diagnostic OGD code (G6500) submitted instead of G4440, or G4440 submitted for a RIG procedure. Fix: have someone who has read the operative report confirm the code, rather than relying on the booking note.
• Weak clinical case. The referral letter states “needs PEG” without documenting the underlying diagnosis and why oral nutrition is insufficient or unsafe. Fix: the consultant letter should include the diagnosis, the indication, and a reference to relevant clinical guidelines.
• Unbundling error. G6500, G4410 or G4430 billed on the same episode as G4440. Fix: when G4440 is submitted, keep every other OGD code off the same invoice.
• Indication outside policy cover. Some insurers exclude certain chronic conditions from cover. Check the patient’s policy schedule before performing elective PEG insertion privately.

Fee expectations and schedule position for CCSD Code G4440

G4440 sits in the therapeutic OGD section of the upper GI endoscopy chapter. Each insurer sets its own fees, not CCSD. The CCSD schedule supplies the code, and each insurer’s fee schedule sets what it pays recognised consultants.

Specific fee figures are not published here because insurer rates change. Instead, consultants should check the current code wording on the CCSD website and verify rates with each insurer. Bupa, AXA Health, Aviva and Vitality each publish fee schedules or fee-finder tools for recognised consultants.

How Pabau keeps G4440 claims complete before submission

In many private gastroenterology practices, the pieces of a G4440 claim live in different places. The consent sits in a paper file, the endoscopy report in the hospital system, and the authorisation reference in an email. The claim goes out when someone has chased all three.

Pabau holds them in one patient record instead. Patients sign digital consent forms before the list, and procedure notes are written against the appointment. The claim then goes to the insurer through Healthcode from that same record.

As a result, the practice sees fewer queries about missing documents and spends less time chasing paperwork after the procedure.

Get G4440 claims paid first time

Pabau keeps the consent, endoscopy report and authorisation reference in one patient record, so G4440 claims reach insurers complete.

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Conclusion

Code G4440 from the operative report, not the booking note. If the report shows a PEG or PEJ placed at OGD, G4440 is the only OGD code on the invoice. If it shows fluoroscopy and no endoscope, G4440 does not apply.

The work that protects the claim happens before the procedure. First, confirm the insurer’s authorisation rule, and make sure the consent and referral letter name the indication. As a result, a claim built that way rarely comes back for a second round.

Book a demo to see how Pabau keeps consent, procedure notes and insurer claims together for private gastroenterology practices.

Continue your research

Need a starting point for CCSD billing in private practice? Bupa CCSD procedure codes covers the structure of the Bupa code schedule, recognition requirements, and how to navigate the Bupa provider portal.

Looking to reduce claim rejections across your private caseload? Claims management software explains how pre-submission checks and digital claim workflows reduce avoidable denials.

Closing a gastrostomy tract after the tube comes out? CCSD Code G3440 covers how closure of a gastrostomy is coded and documented.

Looking up another CCSD code? CCSD codes collects the procedure code guides for UK private practice billing.

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