2025 CPT code 44369
(Active) Effective Date: N/A Revision Date: N/A Surgery - Endoscopy Digestive System Feed
Small intestinal endoscopy, beyond the second part of the duodenum but not including the ileum; with ablation of lesions.
Modifiers may apply depending on the circumstances of the service, including location, anesthesia, and assisting physicians.Consult current modifier guidelines.
Medical necessity for 44369 is established when there is clinical indication for small bowel visualization beyond the duodenum, such as unexplained gastrointestinal bleeding, recurrent abdominal pain, suspected Crohn’s disease, or other conditions where small bowel lesions are suspected.
The gastroenterologist or surgeon is responsible for performing the procedure, including pre-procedural evaluation, informed consent, procedure execution, post-procedural care, and interpreting results.
In simple words: The doctor uses a thin, flexible tube with a camera and light (endoscope) to examine the small intestine.If they find any abnormal growths (tumors or polyps), they destroy them using laser or radio waves. This procedure doesn't reach the very end of the small intestine.
This CPT code describes antegrade small bowel enteroscopy extending beyond the second portion of the duodenum, but not reaching the ileum.The procedure involves the ablation of tumors, polyps, or other lesions unsuitable for removal via hot biopsy forceps, bipolar cautery, or snare techniques.Ablation is accomplished using methods such as laser or radiofrequency energy. The procedure is performed using a flexible fiberoptic endoscope.
Example 1: A patient presents with obscure gastrointestinal bleeding.After negative upper endoscopy, 44369 is used to visualize the jejunum, identify the bleeding source, and perform ablation of a small angiodysplasia., A patient with recurrent abdominal pain undergoes small bowel enteroscopy (44369). Multiple polyps are discovered in the jejunum and are ablated. Biopsies are taken for histopathological examination., A patient with a known history of Crohn’s disease undergoes small bowel enteroscopy (44369) for assessment of disease activity and stricture. Laser ablation is used to improve luminal patency.
* Pre-procedure diagnostic imaging (e.g., abdominal CT scan or capsule endoscopy)* Informed consent documentation.* Procedure report detailing the extent of the examination, location and type of lesions encountered, and the method of ablation used.* Pathology reports if biopsies are performed.* Post-procedure care notes.* Anesthesia records.
** This procedure requires specialized endoscopy equipment and expertise.Always refer to the latest CPT codebook and payer guidelines for the most up-to-date information.
- Revenue Code: Refer to your specific payer's revenue code guidelines.
- RVU: The RVUs for this code vary depending on the geographic location and the payer.Consult the CMS Physician Fee Schedule for the most up-to-date RVU values.
- Global Days: The global period for this procedure is dependent on the specific service and payer rules.Check payer guidelines for specific global period days.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is generally not applicable to this code, as it typically represents a complete service performed by the physician.
- Fee Schedule: Fee schedules vary by payer and location. Check payer guidelines or fee schedule databases.
- Specialties:Gastroenterology, Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office