How To Use CPT Code 44360

CPT 44360 describes the procedure for small intestinal endoscopy, specifically enteroscopy beyond the second portion of the duodenum, excluding the ileum. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 44360?

CPT 44360 is used to describe a specific procedure known as small intestinal endoscopy. This procedure involves the use of an endoscope, a tubular instrument with a light source and camera, to examine a portion of the small intestine. The provider inserts the endoscope through the mouth and examines the first and second parts of the duodenum, as well as the jejunum. However, the procedure does not include the ileum, which is the terminal portion of the small intestine. The purpose of this procedure is to identify any abnormalities or causes for gastrointestinal symptoms such as bleeding or diarrhea. If necessary, the provider may collect samples of suspicious tissue by brushing or washing the area for further laboratory analysis.

2. Official Description

The official description of CPT code 44360 is: ‘Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)’. This code specifically refers to the diagnostic aspect of the procedure, including the collection of specimens by brushing or washing if necessary.

3. Procedure

1. The provider begins by preparing the patient and ensuring they are appropriately prepped and anesthetized for the procedure.
2. A plastic mouthpiece, also known as a bite block, is placed in the patient’s mouth to keep it open during the procedure.
3. The provider inserts a thin, flexible endoscope through the mouthpiece and advances it towards the stomach.
4. As the patient swallows, the provider guides the endoscope through the stomach and into the first portion of the small intestine, known as the duodenum.
5. A small camera attached to the endoscope transmits images to a TV monitor, allowing the provider to visualize the intestinal lining and internal structures.
6. The provider inspects the mucosal lining of the esophagus, stomach, upper portion of the duodenum, and the second portion of the duodenum.
7. If necessary, the provider may continue the examination beyond the second part of the duodenum and into the jejunum, excluding the ileum.
8. If suspicious tissue is identified, the provider may perform brushing or washing with a cleansing agent to collect samples for laboratory examination.
9. Once the examination and any necessary specimen collection are complete, the provider removes all instruments and withdraws the endoscope.

4. Qualifying circumstances

CPT 44360 is typically performed on patients who are experiencing gastrointestinal symptoms or have a suspected abnormality in the small intestine. The procedure is used to diagnose the type of disease and its causes. It is important to note that CPT 44360 specifically focuses on the examination of the small intestine beyond the second portion of the duodenum, excluding the ileum. The provider must document the medical necessity for performing this procedure and ensure that it is appropriate for the patient’s condition.

5. When to use CPT code 44360

CPT code 44360 should be used when the provider performs a small intestinal endoscopy that goes beyond the second portion of the duodenum but does not include the ileum. This code is specifically for diagnostic purposes and includes the collection of specimens by brushing or washing if performed as a separate procedure. It is important to review the documentation and ensure that the procedure meets the criteria outlined in the code description before reporting CPT 44360.

6. Documentation requirements

To support a claim for CPT 44360, the provider must document the following information:

• Reason for performing the small intestinal endoscopy
• Specific areas of the small intestine examined, including the first and second parts of the duodenum and the jejunum
• Details of any specimen collection performed, such as brushing or washing
• Date and duration of the procedure
• Any abnormalities or findings observed during the examination
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 44360, it is important to ensure that the procedure meets the criteria outlined in the code description. The provider should report this code when performing a small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum, for diagnostic purposes. It is also important to review any additional services performed during the procedure and determine if they should be reported separately. For accurate billing, it is recommended to consult the official coding guidelines and any payer-specific requirements.

8. Historical information

CPT code 44360 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2015, which expanded the description to include the option of collecting specimens by brushing or washing. There have been no further updates or changes to the code since then.

9. Examples

1. A patient presents with chronic abdominal pain and gastrointestinal bleeding. The provider performs a small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum, to identify the source of the bleeding.