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2025 CPT code 44364

Small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, not including the ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.

Do not report 44364 with codes for procedures performed proximal to the second portion of the duodenum. If the ileum is reached, a different code is required. Control of bleeding during the same operative session is not reported separately.

Medical necessity for this procedure must be established by documenting the patient’s symptoms (e.g., bleeding, abdominal pain), prior imaging or test results suggesting a small intestinal abnormality, or a need for surveillance due to a condition like Peutz-Jeghers syndrome.

The physician is responsible for performing the enteroscopy, including insertion and navigation of the endoscope, identification and removal of lesions using the snare technique, and management of any complications. They must also document the procedure, including findings, techniques used, and any specimens taken.

In simple words: The doctor uses a thin, flexible tube with a camera to look inside your small intestine. They go past the first two sections but don't go all the way to the end. If they find any growths like polyps or tumors, they use a special tool like a tiny lasso to remove them.

This procedure involves the insertion of a flexible, fiberoptic endoscope through the mouth and into the small intestine, extending past the second part of the duodenum but not reaching the ileum.The purpose is to visualize and examine the lining of the small intestine. During the procedure, any identified tumors, polyps, or other lesions are removed using a snare technique. This involves passing a wire loop through the endoscope, encircling the growth, and then tightening the loop to remove it.

Example 1: A patient presents with obscure gastrointestinal bleeding.An enteroscopy is performed, and an angiodysplasia in the jejunum is identified and removed via snare technique., During a routine screening enteroscopy, a small polyp is discovered in the duodenum and removed with a snare., A patient with Peutz-Jeghers syndrome undergoes surveillance enteroscopy. Several small intestinal polyps are identified and removed by snare technique to prevent future complications.

Documentation should include the extent of the examination (how far the endoscope advanced), identification of any lesions (size, location, and number), method of removal (snare), and any complications. Photographs or video recordings of the procedure are also recommended.

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