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Official Description

Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Ileoscopy is a medical procedure that involves the examination of the ileum, which is the final section of the small intestine, through an existing stoma, specifically an ileostomy. This procedure is classified as diagnostic and may include the collection of specimens through techniques such as brushing or washing. The ileoscopy is performed using an endoscope, a flexible tube equipped with a camera and light source, which is inserted into the ileum via the stoma. The primary goal of this procedure is to visualize the mucosal lining of the ileum, allowing healthcare professionals to assess for any abnormalities or diseases present in this segment of the gastrointestinal tract. During the procedure, the ileum is inflated with a small amount of air to enhance visibility by expanding the mucosal folds. This inflation aids in a thorough inspection of the mucosa. Additionally, if necessary, cell samples can be collected by introducing saline fluid into the small intestine and retrieving it, which can provide valuable information for diagnostic purposes. The procedure may also involve obtaining tissue samples through biopsy, which is performed using specialized forceps that are passed through the endoscope. The collected samples are then sent for laboratory analysis to assist in diagnosing any underlying conditions. Overall, ileoscopy is a critical procedure for evaluating the health of the ileum and can provide essential insights into gastrointestinal disorders.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The ileoscopy procedure is indicated for various clinical scenarios where direct visualization of the ileum is necessary. The following conditions may warrant the performance of ileoscopy:

  • Evaluation of Ileal Disorders The procedure is performed to assess for abnormalities such as inflammation, strictures, or tumors within the ileum.
  • Investigation of Gastrointestinal Symptoms Ileoscopy may be indicated in patients presenting with unexplained gastrointestinal symptoms, including abdominal pain, diarrhea, or gastrointestinal bleeding.
  • Surveillance for Disease Recurrence Patients with a history of inflammatory bowel disease or previous ileal surgery may require ileoscopy for monitoring potential disease recurrence or complications.
  • Specimen Collection The procedure allows for the collection of cell samples through brushing or washing, which can be crucial for diagnostic purposes.

2. Procedure

The ileoscopy procedure involves several key steps to ensure effective examination and specimen collection. The following outlines the procedural steps:

  • Preparation and Anesthesia The patient is prepared for the procedure, which may include fasting and the administration of sedation or anesthesia to ensure comfort during the examination.
  • Insertion of the Endoscope The endoscope is carefully inserted through the stoma into the ileum. The healthcare provider ensures that the scope is positioned correctly to allow for optimal visualization of the mucosal lining.
  • Inflation of the Ileum A small amount of air is introduced into the ileum to inflate the intestinal walls. This inflation helps to expand the mucosal folds, enhancing visibility and allowing for a thorough inspection of the ileal mucosa.
  • Inspection of the Mucosa The endoscope is advanced along the ileum, and the mucosa is meticulously inspected for any signs of abnormalities, such as lesions, inflammation, or strictures.
  • Specimen Collection If indicated, cell samples are collected by introducing saline fluid into the ileum and then retrieving it. This process involves brushing or washing the mucosal surface to gather cellular material for analysis.
  • Biopsy (if necessary) If any suspicious areas are identified, biopsy forceps are introduced through the endoscope. The forceps are opened to capture tissue samples, which are then removed and sent for laboratory analysis.
  • Inspection Post-Specimen Collection After specimen collection, the area is re-inspected to ensure that no injuries have occurred during the procedure and to confirm the success of the examination.
  • Completion of the Procedure Once the examination and any necessary interventions are complete, the endoscope is carefully withdrawn, and the procedure is concluded.

3. Post-Procedure

Following the ileoscopy, patients may experience some mild discomfort or cramping, which is typically temporary. It is essential for healthcare providers to monitor the patient for any immediate complications, such as bleeding or perforation. Patients are usually advised to rest and may be given specific dietary instructions to follow after the procedure. The results of any collected specimens will be communicated to the patient once laboratory analysis is complete, and further management will be discussed based on the findings. It is important for patients to report any unusual symptoms, such as severe pain or persistent bleeding, to their healthcare provider promptly.

Short Descr SMALL BOWEL ENDOSCOPY BR/WA
Medium Descr ILEOSCOPY THRU STOMA DX W/COLLJ SPEC WHEN PRFMD
Long Descr Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple 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) 1 - Statutory 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.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
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.
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).
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).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
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.
74 Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
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.)
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.)
81 Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
GC This service has been performed in part by a resident under the direction of a teaching physician
KX Requirements specified in the medical policy have been met
LT Left side (used to identify procedures performed on the left side of the body)
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
SG Ambulatory surgical center (asc) facility service
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
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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Notes
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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