© Copyright 2025 American Medical Association. All rights reserved.
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 particularly important for diagnosing and managing conditions that may cause gastrointestinal bleeding. During the endoscopy, the patient is typically administered a local anesthetic to numb the mouth and throat, facilitating the insertion of a flexible fiberoptic endoscope. This endoscope is a thin, flexible tube equipped with a light and camera, which is carefully advanced through the digestive tract. The examination begins as the endoscope is swallowed, allowing it to navigate through the esophagus and into the stomach, and subsequently into the duodenum. Once the endoscope reaches the duodenum, the mucosal surfaces of the duodenum, jejunum, and ileum are meticulously inspected for any abnormalities, such as lesions, ulcers, or sources of bleeding. The procedure not only involves visual inspection but also includes therapeutic interventions to control any identified bleeding. Various techniques may be employed, including the use of thermal modalities like bipolar or unipolar cautery, heater probes, or laser devices. These methods apply heat to the bleeding site to promote coagulation and stop the hemorrhage. Additionally, pharmacological agents such as epinephrine may be injected to constrict blood vessels and assist in controlling the bleeding. The procedure may also involve the use of staples or hemoclips to close any tears or lacerations in the intestinal wall. Overall, this endoscopic procedure is a critical tool in the management of gastrointestinal bleeding and other related conditions, providing both diagnostic and therapeutic capabilities.
© Copyright 2025 Coding Ahead. All rights reserved.
The small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, is indicated for various clinical scenarios where direct visualization and intervention in the small intestine are necessary. The following conditions may warrant this procedure:
The procedure of small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, involves several critical steps to ensure effective examination and treatment:
After the completion of the small intestinal endoscopy, the patient is monitored for any immediate complications or adverse effects. Post-procedure care typically includes observation for signs of bleeding, perforation, or infection. Patients may experience some discomfort or throat irritation due to the anesthetic used during the procedure. It is essential to provide instructions regarding dietary restrictions and activity levels following the procedure. Patients are usually advised to start with clear liquids and gradually progress to a regular diet as tolerated. Follow-up appointments may be scheduled to discuss findings and any further management required based on the results of the endoscopy.
| Short Descr | SMALL BOWEL ENDOSCOPY | Medium Descr | ENTEROSCOPY > 2ND PRTN ILEUM CONTROL BLEEDING | Long Descr | Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) | 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 | 93 - Other non-OR upper GI therapeutic procedures |
| XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient 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. | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | SG | Ambulatory surgical center (asc) facility service | 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. |
| 2002-01-01 | Changed | Code description changed. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
Get instant expert-level medical coding assistance.