2025 CPT code 44363
(Active) Effective Date: N/A Endoscopic Small Intestine Procedures - Surgical Procedures on the Digestive System Surgery Feed
Small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, not including the ileum; with removal of foreign body(s).
Modifiers may be applicable to this code.Modifier 22 (Increased Procedural Services) may be used if the procedure is significantly more complex than usual, for example due to the location or composition of the foreign body.Modifier 53 (Discontinued Procedure) would be used if the procedure is terminated before completion.Modifier 59 (Distinct Procedural Service) may be needed to distinguish the procedure if other endoscopic procedures are performed on the same day.Modifier 78 is for an unplanned return to the procedure room.
Medical necessity for this procedure must be established by documenting the patient’s signs, symptoms, or conditions that justify the removal of the foreign body(s). The documentation should also explain why a less invasive procedure would not be appropriate.This could include the size or location of the foreign body, the presence of symptoms, or the risk of complications if the foreign body is not removed.
The physician is responsible for performing the enteroscopy, including insertion and advancement of the enteroscope, visualization and examination of the small intestine, removal of any foreign bodies, and documentation of the findings.
In simple words: The doctor uses a thin, flexible tube with a camera and light (endoscope) to look inside your small intestine. They put it in through your mouth and go past the first two parts of your small intestine, into an area called the jejunum, but not as far as the ileum. If they find anything stuck in there, they can remove it with tools they put through the tube.
This procedure involves the insertion of a flexible endoscope, called an enteroscope, through the mouth and into the small intestine. The enteroscope is advanced beyond the second part of the duodenum and into the jejunum, but does not reach the ileum. The procedure is performed to examine the lining of the small intestine for abnormalities and to remove any foreign bodies that may be present. It includes the removal of the foreign body(s) using instruments passed through the endoscope.
Example 1: A patient presents with abdominal pain and a history of swallowing a small toy. An enteroscopy is performed, and the toy is located and removed from the jejunum., A patient experiences chronic bleeding from the small intestine. Enteroscopy is used to identify the source of the bleeding, which is determined to be an angiodysplasia in the jejunum., A patient has suspected Crohn's disease. An enteroscopy is performed to examine the small intestine for inflammation and ulcerations and to obtain biopsies for further evaluation.
Documentation should include details of the procedure, including the insertion site, the extent of the examination (e.g., the specific segments of the small intestine visualized), the methods used to remove the foreign body(s), and any complications encountered.The type and size of the foreign body should be documented.The medical necessity of the procedure, relating the signs, symptoms, and/or reason for the removal of the foreign object should be documented.If biopsies are taken, they should be documented separately.