2025 CPT code 44378
Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, including the ileum; with control of bleeding.
Medical necessity for 44378 is established by the presence of signs or symptoms suggesting a small bowel pathology requiring endoscopic evaluation and potential intervention for bleeding, such as obscure gastrointestinal bleeding, suspected Crohn's disease, or surveillance in patients with known small bowel disorders.
The physician is responsible for performing the enteroscopy, controlling any bleeding, and managing the patient's sedation. They must also document the procedure thoroughly, including the extent of the examination and the methods used for bleeding control.
In simple words: The doctor uses a thin, flexible tube with a camera and light (endoscope) to look inside your small intestine, all the way to the end (ileum). If there's any bleeding, they'll stop it during the procedure using different tools.
This code describes a procedure where a physician performs a small intestinal endoscopy, advancing the endoscope beyond the second portion of the duodenum to reach the ileum. During the procedure, the physician also controls any bleeding encountered, using methods like injection, bipolar/unipolar cautery, laser, heater probe, stapler, or plasma coagulator.
Example 1: A patient presents with obscure gastrointestinal bleeding. An enteroscopy is performed, reaching the ileum, and a bleeding angiodysplasia is identified and treated with argon plasma coagulation., During an enteroscopy for suspected Crohn's disease, a bleeding ulcer is found in the ileum and is treated with injection therapy., A patient with Peutz-Jeghers syndrome undergoes surveillance enteroscopy. A small bleeding polyp is found in the jejunum and removed with a snare cautery.
Documentation should include the indication for the procedure, the extent of the examination (specifically mentioning reaching the ileum), the location and description of any bleeding sites, the method(s) used to control bleeding, and any complications encountered.
** Please always refer to current CPT coding guidelines and NCCI edits for the most up-to-date information.
- Specialties:Gastroenterology
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Office