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Official Description

Ileoscopy, through stoma; with biopsy, single or multiple

© 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 performed using an endoscope, a flexible tube equipped with a camera and light, allowing healthcare professionals to visualize the mucosal lining of the ileum. During ileoscopy, biopsies may be taken, which involves the removal of small tissue samples for further analysis. The procedure is essential for diagnosing various gastrointestinal conditions, as it enables direct observation of the ileal mucosa and the collection of samples for laboratory testing. The process may also include additional techniques such as brushing or washing cell samples and transendoscopic balloon dilation, which can help in managing strictures or narrowing within the ileum. Overall, ileoscopy through stoma is a critical tool in the evaluation and management of intestinal diseases, providing valuable insights into the health of the gastrointestinal tract.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The ileoscopy procedure is indicated for various gastrointestinal conditions that may affect the ileum. These indications include:

  • Evaluation of Inflammatory Bowel Disease (IBD) - This includes conditions such as Crohn's disease and ulcerative colitis, where inflammation of the intestinal lining is present.
  • Assessment of Ileal Strictures - Narrowing of the ileum can lead to obstruction, and ileoscopy allows for direct visualization and potential intervention.
  • Detection of Neoplasms - The procedure can help identify tumors or abnormal growths within the ileum.
  • Investigation of Gastrointestinal Bleeding - Ileoscopy can be utilized to locate the source of unexplained bleeding in the gastrointestinal tract.
  • Surveillance for Dysplasia - In patients with a history of IBD, regular ileoscopy may be performed to monitor for precancerous changes in the mucosa.

2. Procedure

The ileoscopy procedure involves several key steps to ensure effective examination and intervention:

  • Step 1: 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.
  • Step 2: Insertion of the Endoscope - The endoscope is carefully inserted through the ileostomy opening into the ileum. This allows the physician to visualize the intestinal lining directly.
  • Step 3: Inflation of the Ileum - A small amount of air is introduced into the ileum to expand the mucosal folds. This inflation enhances visibility and allows for a more thorough inspection of the mucosa.
  • Step 4: Inspection of the Mucosa - The physician advances the endoscope along the ileum, meticulously inspecting the mucosal surface for any abnormalities, such as inflammation, lesions, or strictures.
  • Step 5: Biopsy Collection - If any suspicious areas are identified, biopsy forceps are introduced through the endoscope's biopsy channel. The forceps are opened to capture tissue samples, which are then removed for laboratory analysis. Multiple biopsies may be taken as needed.
  • Step 6: Additional Procedures - If indicated, brushing or washing techniques may be employed to collect cell samples. Additionally, if a stricture is identified, transendoscopic balloon dilation may be performed to widen the narrowed area.
  • Step 7: Dilation of Stricture - For balloon dilation, a deflated balloon catheter is positioned at the stricture site. The balloon is inflated to a predetermined pressure, held for a short duration, and then deflated and removed, followed by inspection of the area to ensure successful dilation.

3. Post-Procedure

After the ileoscopy procedure, patients are typically monitored for any immediate complications. They may experience some discomfort or cramping, which is generally mild and resolves quickly. Recovery time can vary, but most patients can resume normal activities within a short period. The physician will provide specific post-procedure care instructions, which may include dietary recommendations and signs of potential complications to watch for, such as excessive bleeding or signs of infection. The collected tissue and cell samples will be sent for laboratory analysis, and results will be discussed with the patient during a follow-up appointment.

Short Descr SMALL BOWEL ENDOSCOPY
Medium Descr ILEOSCOPY STOMA W/BX SINGLE/MULTIPLE
Long Descr Ileoscopy, through stoma; 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) 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.
Endoscopic Base Code 44380  Ileoscopy, through stoma; 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 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.
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.)
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
GW Service not related to the hospice patient's terminal condition
PT Colorectal cancer screening test; converted to diagnostic test or other procedure
SG Ambulatory surgical center (asc) facility service
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.
Pre-1990 Added Code added.
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