2025 CPT code 44361
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, not including the ileum; with biopsy, single or multiple.
Modifiers may be applicable to this code. For example, modifier 22 (Increased Procedural Services) might be used if the procedure is significantly more complex than usual.
Medical necessity must be established for this procedure. The documentation should clearly indicate the clinical rationale for performing the enteroscopy and biopsy, such as signs, symptoms, or other objective findings suggestive of a small intestinal disorder.
The physician is responsible for preparing the patient, performing the endoscopy, obtaining biopsy samples, and ensuring proper documentation of the procedure.
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 procedure examines the part of the small intestine past the duodenum but before the ileum.
This code describes a procedure where a physician uses an endoscope to visualize the small intestine beyond the second part of the duodenum, up to but not including the ileum. During the procedure, one or more biopsies are taken from the intestinal lining.
Example 1: A patient presents with chronic abdominal pain and suspected Crohn's disease. An enteroscopy with biopsy is performed to examine the jejunum for inflammation and ulceration., During an endoscopic evaluation for iron deficiency anemia, the physician advances the endoscope beyond the duodenum into the jejunum and takes biopsies to assess for abnormalities., A patient with a history of celiac disease undergoes an enteroscopy with biopsy to monitor the healing of the small intestine and rule out complications.
Documentation should include the indication for the procedure, the extent of the examination (specifying the areas of the small intestine visualized), the number and location of biopsies taken, and any findings or complications encountered during the procedure.
** Always ensure documentation supports medical necessity and accurately reflects the procedure performed.For procedures including the ileum, use codes 44376-44379.
- Revenue Code: P8I (ENDOSCOPY - OTHER)
- RVU: Medicare Physician Fee Schedule: $153
- Payment Status: Active
- Fee Schedule: Information available from sources like Medicare.gov shows national average fees for hospitals and ambulatory surgical centers.
- Specialties:Gastroenterology, General Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Inpatient Hospital (if performed during an inpatient admission)