Nasogastric Tube Placement
Nasogastric tube placement, [right / left] naris
[Bowel obstruction / Ileus / Upper GI bleeding / Need for enteral access] requiring nasogastric tube placement for [gastric decompression / enteral feeding / medication administration / monitoring of upper GI bleeding].
[Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives / The procedure was emergent, and consent was implied].
[***, MD/DO]
[None / Topical lidocaine spray to the posterior pharynx]
Gastric position was confirmed by [chest radiograph showing the tube tip below the diaphragm in the gastric body / aspiration of gastric contents with pH ≤5][ and auscultation of insufflated air over the epigastrium]. [X] mL of [bilious / blood-tinged / dark green / clear] gastric contents drained immediately.
A time-out was completed confirming the patient and procedure. The head of the bed was elevated to 30–45 degrees. Patency of the [right / left] naris was confirmed, and insertion length was estimated with the nose-earlobe-xiphoid (NEX) measurement.
[The posterior pharynx was anesthetized with topical lidocaine spray.] The tube was lubricated with water-soluble lubricant, inserted through the naris, and advanced posteriorly along the floor of the nasal cavity. The patient swallowed repeatedly [with sips of water through a straw] as the tube was advanced through the esophagus into the stomach to the measured depth.
The tube was secured to the nose with tape and connected to drainage.
[X] Fr nasogastric tube, [right / left] naris, secured at [X] cm at the naris, to [intermittent low wall suction / gravity drainage]
None
[None / Gastric aspirate sent for analysis]
None
The patient tolerated the procedure without significant discomfort, and the tube is functioning. [Chest radiograph confirmation of position is pending, and the tube will not be used for feeds or medications until position is confirmed.] Output will be recorded.
Epic SmartPhrase Version
PROCEDURE: Nasogastric tube placement, [right / left] naris
INDICATION: *** requiring nasogastric tube placement for ***.
CONSENT: [Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives / Emergent, consent implied].
PERFORMED BY: ***, MD/DO
ANESTHESIA: [None / Topical lidocaine spray to posterior pharynx]
FINDINGS: Gastric position confirmed by ***. *** mL *** contents drained immediately.
PROCEDURE DETAILS:
Time-out completed. HOB 30–45 degrees. *** naris patency confirmed. NEX measurement calculated. [Posterior pharynx anesthetized with topical lidocaine.] NGT lubricated and advanced along nasal floor. Patient swallowed as tube advanced to measured depth. Tube secured with tape, connected to drainage.
DEVICE PLACED: *** Fr NGT, *** naris, secured at *** cm at naris, to [intermittent low wall suction / gravity drainage]
EBL: None
SPECIMENS: None
COMPLICATIONS: None
POST-PROCEDURE PLAN: Tolerated well, tube functioning. [CXR confirmation pending, no feeds or medications until position confirmed.] Output to be recorded.
Signed: .ME, .MYDEGREE
.TODAYVariants
Difficult Placement: Stylet / Ice Water Technique
Initial placement was unsuccessful due to [coiling in the posterior pharynx / patient agitation / altered anatomy]. The tube was stiffened by [placement in ice water for 5 minutes / use of the internal stylet] and reattempted with the head in a more flexed position. Successful placement was confirmed on the second attempt. Stylet was removed prior to securing the tube. Position confirmed by CXR before use.
Post-Pyloric Feeding Tube (Dobhoff)
A [10 Fr] Dobhoff tube with stylet was placed for post-pyloric enteral feeding given [aspiration risk / gastroparesis / pancreatitis]. The tube was advanced to 90 cm. Position was confirmed by [abdominal radiograph showing the weighted tip beyond the pylorus in the duodenum / fluoroscopy]. The stylet was removed only after radiographic confirmation of position. The tube was secured and marked at the naris.
Charting Tips
- Always document the method of position confirmation before the tube is used. CXR is the gold standard. Auscultation alone is insufficient and has been associated with inadvertent pulmonary placement. Document CXR result explicitly.
- For Dobhoff or feeding tubes with stylets, document that the stylet was removed only after radiographic confirmation of correct position. Stylet-related small bowel perforations are a known complication of premature stylet removal.
- Document tube size (Fr), naris used, insertion depth at the naris, and initial output character and volume. This establishes the baseline for nursing to detect tube migration.
Documentation & Reimbursement Considerations
- Primary service: Report Nasogastric Tube Placement as the primary service when it is the definitive operation performed.
- In most inpatient settings, NGT placement by nursing is not separately billable by the physician. Tube placement requiring physician skill (0.79 wRVU, 0-day global) applies when a physician places the tube due to clinical complexity.
- Physician billing requires documentation of why physician involvement was medically necessary, such as altered anatomy, failed nursing placement, or high aspiration risk.
- 0-day global: no bundled postoperative period. If placed as part of a separate operative procedure, it is typically bundled and not separately billed.
- Fluoroscopic guidance during NGT placement (e.g., for small bowel access) can be billed separately. Document the need for guidance and confirm the image record is saved.
- For long-term enteral access, PEG tube or surgical jejunostomy services apply. NGT placement is not billable as a feeding tube procedure.