2025 CPT code 44365
Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
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 hot biopsy forceps or bipolar cautery.
Modifiers may be applicable to indicate specific circumstances, such as increased procedural services (modifier 22) or multiple procedures (modifier 51).
Medical necessity must be established for this procedure.Appropriate indications may include obscure gastrointestinal bleeding, suspected Crohn's disease, surveillance for polyposis syndromes, or other diagnostic or therapeutic purposes.
The physician is responsible for performing the enteroscopy, including inserting and maneuvering the endoscope, identifying and removing any lesions, and managing any complications that may arise. They must also ensure appropriate documentation of the procedure.
In simple words: The doctor uses a thin, flexible tube with a camera (an endoscope) to look inside your small intestine.They go past the first two sections of the small intestine but don't go as far as the last part (the ileum).If they find any growths or abnormal tissue, they can remove them during the same procedure using tools passed through the endoscope.
This code describes a procedure where a physician uses an endoscope to visualize and examine the small intestine beyond the second part of the duodenum, up to but not including the ileum. During the procedure, any identified tumors, polyps, or other lesions are removed using hot biopsy forceps or bipolar cautery.The procedure involves inserting a flexible, fiberoptic endoscope through the mouth and advancing it through the esophagus, stomach, and into the small intestine. The endoscope has a camera that transmits images to a monitor, allowing the physician to view the intestinal lining.If necessary, an incision in the abdomen may be used to assist the endoscopy.
Example 1: A patient presents with obscure gastrointestinal bleeding.An enteroscopy is performed to examine the small bowel beyond the duodenum, and a bleeding angiodysplasia is found and treated with bipolar cautery., A patient with suspected Crohn's disease undergoes an enteroscopy.Multiple small bowel biopsies are taken, and a small polyp is removed using hot biopsy forceps., A patient with Peutz-Jeghers syndrome undergoes surveillance enteroscopy.Several small polyps are identified and removed throughout the jejunum.
Documentation should include the extent of the examination (how far the endoscope advanced), the location and description of any lesions, the method of removal, and any complications encountered.The indication for the procedure should also be documented.
- Specialties:Gastroenterology
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, or other appropriate outpatient settings.