© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 44365 refers to a specific medical procedure known as small intestinal endoscopy, particularly focusing on the enteroscopy that extends beyond the second portion of the duodenum, excluding the ileum. This procedure involves the endoscopic examination of the small intestine, where the physician inspects the mucosal surfaces for any abnormalities. During this examination, the physician may encounter tumors, polyps, or other lesions that require removal. The removal of these lesions is accomplished using specialized tools such as hot biopsy forceps or bipolar cautery. The procedure begins with the administration of an anesthetic spray to numb the mouth and throat, followed by the insertion of a flexible fiberoptic endoscope. This endoscope is advanced through the gastrointestinal tract, allowing for direct visualization of the duodenum and potentially the jejunum. The procedure is designed to provide a thorough inspection and intervention for lesions that may pose health risks, ensuring that any identified abnormalities are addressed effectively. The use of hot biopsy forceps allows for simultaneous removal and cauterization of tissue, while bipolar cautery provides an alternative method for lesion removal, utilizing electrical current to achieve the same outcome. This procedure is critical for diagnosing and treating conditions affecting the small intestine, particularly in cases where lesions are present.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 44365 is indicated for the following conditions:
The procedure begins with the administration of an anesthetic spray to numb the patient's mouth and throat, facilitating the insertion of the endoscope. Following this, a hollow mouthpiece is placed in the patient's mouth to maintain an open airway. The flexible fiberoptic endoscope is then carefully inserted and advanced as the patient swallows, allowing the endoscope to navigate through the esophagus and into the stomach. Once the endoscope passes beyond the cricopharyngeal region, it is guided into the duodenum under direct visualization. The physician inspects the mucosal surfaces of the duodenum and continues the examination into the jejunum, ensuring that any abnormalities are noted. After the initial inspection, the endoscope is withdrawn, allowing for a second inspection of the entire circumference of the duodenum and jejunum. If lesions are identified, the procedure may involve the use of hot biopsy forceps or bipolar cautery for their removal. In the case of hot biopsy forceps, insulated monopolar forceps are utilized to simultaneously remove and electrocoagulate the tissue. Alternatively, bipolar cautery employs electrical current that flows between two points on the forceps to achieve similar results. This step is crucial for the effective removal of small polyps and the treatment of vascular ectasias, ensuring that any identified lesions are addressed appropriately.
After the completion of the procedure, patients are typically monitored for any immediate complications or adverse reactions to the anesthesia. It is common for patients to experience some throat discomfort or mild abdominal cramping following the endoscopy. Recovery time may vary, but patients are generally advised to rest and avoid strenuous activities for the remainder of the day. Follow-up care may include instructions on dietary modifications or medications to manage any discomfort. Additionally, the physician may schedule a follow-up appointment to discuss the results of the procedure and any further treatment options if necessary. It is important for patients to report any unusual symptoms, such as severe pain, fever, or bleeding, to their healthcare provider promptly.
| Short Descr | SMALL BOWEL ENDOSCOPY | Medium Descr | ENTEROSCOPY > 2ND PRTN W/RMVL LESION CAUTERY | Long Descr | Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery | 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 | 99 - Other OR gastrointestinal therapeutic procedures |
| 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. | 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). | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 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 |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
Get instant expert-level medical coding assistance.