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A small intestinal endoscopy, specifically an enteroscopy beyond the second portion of the duodenum, is a procedure that allows for direct visualization and examination of the small intestine, including the ileum. This procedure is performed using a flexible fiberoptic endoscope, which is a long, thin tube equipped with a light and camera. The endoscope is inserted through the mouth and advanced through the gastrointestinal tract until it reaches the desired area of the small intestine. During this examination, the physician can inspect the mucosal surfaces of the duodenum, jejunum, and ileum for any abnormalities, such as lesions, inflammation, or other pathological changes. In addition to visual inspection, this procedure may involve the collection of tissue samples for biopsy. Biopsies can be performed using specialized forceps that are passed through a channel in the endoscope. The ability to obtain single or multiple biopsies during the procedure allows for a more comprehensive assessment of the intestinal tissue, which can be crucial for diagnosing various gastrointestinal conditions. The collected tissue samples are then sent for laboratory analysis to provide further insights into the patient's health status. Overall, this procedure is essential for diagnosing and managing conditions affecting the small intestine, enabling healthcare providers to make informed decisions regarding patient care.
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The small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, including ileum, with biopsy is indicated for various gastrointestinal conditions. The following are explicitly provided indications for this procedure:
The procedure involves several key steps to ensure a thorough examination of the small intestine. The following procedural steps are explicitly described:
Post-procedure care involves monitoring the patient for any immediate complications, such as bleeding or perforation, which are rare but possible. Patients may experience some throat discomfort due to the anesthetic spray and the procedure itself. It is important for patients to follow any specific post-procedure instructions provided by their healthcare provider, which may include dietary modifications or restrictions on physical activity. Additionally, the collected tissue samples will be sent for laboratory analysis, and the results will be discussed with the patient in a follow-up appointment to determine any further management or treatment options based on the findings.
| Short Descr | SMALL BOWEL ENDOSCOPY/BIOPSY | Medium Descr | ENTEROSC >2ND PRTN W/ILEUM W/BX SINGLE/MULTIPLE | Long Descr | Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple | 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 | 44376 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (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 | 70 - Upper gastrointestinal endoscopy, biopsy |
| 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). | 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. | 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. | 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.) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | 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. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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