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2025 CPT code 44377

Small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, including the ileum; with biopsy, single or multiple.

When bleeding occurs as a result of the endoscopic procedure, control of bleeding is not reported separately during the same operative session.Do not report 44377 with codes for procedures performed only up to the second portion of the duodenum.

Medical necessity must be established by documenting the clinical signs, symptoms, or other objective findings that justify the need for the procedure. The documentation should also explain why less invasive diagnostic methods were not sufficient.

The physician is responsible for performing the enteroscopy, guiding the endoscope, obtaining biopsies, and managing any complications that may arise during the procedure, such as bleeding.

IMPORTANT:(Do not report 44377 in conjunction with 44360, 44361, 44363, 44364, 44365, 44366, 44369, 44370, 44372, 44373)

In simple words: The doctor uses a thin, flexible tube with a camera to look inside your small intestine and take small tissue samples for testing.

This code describes a procedure where a physician uses a small, flexible tube with a camera (endoscope) to visualize the small intestine beyond the second part of the duodenum, extending to the ileum. During the procedure, one or more tissue samples (biopsies) are taken from the small intestine for diagnostic purposes.

Example 1: A patient presents with chronic abdominal pain and diarrhea. After other diagnostic tests are inconclusive, an enteroscopy with biopsy (44377) is performed to evaluate the small intestine for conditions like Crohn's disease or celiac disease., A patient experiencing obscure gastrointestinal bleeding undergoes an enteroscopy, and a bleeding lesion is identified in the ileum. Biopsies (44377) are taken to determine the cause of the bleeding., A patient with suspected small bowel tumors undergoes an enteroscopy, and biopsies are taken from suspicious areas in the jejunum and ileum (44377) to confirm the diagnosis and guide treatment planning.

Documentation should include the indication for the procedure, the extent of the examination (including the areas reached within the small intestine), the number and location of biopsies taken, and any findings or complications encountered.

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