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The CPT® Code 44363 refers to a specific medical procedure known as small intestinal endoscopy, specifically an enteroscopy that extends beyond the second portion of the duodenum, and includes the removal of foreign body(ies). This procedure is performed to examine the small intestine, which is a crucial part of the digestive system responsible for nutrient absorption. The small intestine is divided into three main sections: the duodenum, jejunum, and ileum, with the duodenum itself further divided into four portions. The second portion of the duodenum is significant as it is where the bile and pancreatic ducts enter, making it a critical area for examination when foreign bodies are suspected. During the procedure, a flexible fiberoptic endoscope is utilized, which allows for direct visualization of the intestinal tract. The endoscope is inserted through the mouth and advanced through the esophagus and stomach into the small intestine. The procedure is typically performed under sedation, and local anesthetic may be applied to the throat to facilitate the insertion of the endoscope. The primary goal of this endoscopic examination is to locate and remove any foreign bodies that may be lodged within the small intestine, which can cause obstruction or injury. The removal techniques may vary depending on the nature of the foreign body, whether it is smooth-edged, impacted, or sharp. Following the removal, the endoscope is reintroduced to inspect the small intestine for any signs of perforation or other injuries that may have occurred during the presence of the foreign body.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 44363 is indicated for the following conditions:
The procedure involves several critical steps to ensure effective examination and removal of foreign bodies from the small intestine:
Following the procedure, the patient is monitored for any immediate complications or adverse reactions to sedation. It is essential to assess the patient's recovery and ensure that they are stable before discharge. The physician may provide specific post-procedure care instructions, which could include dietary modifications or signs and symptoms to watch for that may indicate complications. Follow-up appointments may be scheduled to evaluate the patient's recovery and address any ongoing concerns related to the procedure.
| Short Descr | SMALL BOWEL ENDOSCOPY | Medium Descr | ENTEROSCOPY > 2ND PRTN W/RMVL FOREIGN BODY | Long Descr | Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body(s) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic 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. | Endoscopic Base Code | 44360 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8I - Endoscopy - other | MUE | 1 | CCS Clinical Classification | 229 - Nonoperative removal of foreign body |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 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). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 2015-01-01 | Changed | Description Changed |
| Pre-1990 | Added | Code added. |
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