How To Use CPT Code 44361

CPT 44361 describes the use of an endoscope to examine the small intestines beyond the second part of the duodenum, excluding the ileum, and includes the collection of one or more biopsy samples. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 44361?

CPT 44361 is used to describe the procedure in which a healthcare provider utilizes an endoscope to examine the small intestines beyond the second part of the duodenum, but not including the ileum. During this procedure, the provider may also collect one or more biopsy samples for further examination.

2. Official Description

The official description of CPT code 44361 is: ‘Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple.’

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring they are appropriately prepped and anesthetized.
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, fiberoptic endoscope through the mouthpiece and advances it towards the stomach as the patient swallows.
4. The endoscope is guided through the stomach and into the first portion of the small bowel, known as the duodenum.
5. The provider may use an incision in the abdomen to assist with the endoscopy.
6. A small camera attached to the endoscope sends images to a TV monitor, allowing the provider to visualize the interior structures of the intestines.
7. The provider inspects the mucosal linings of the esophagus, stomach, upper portion of the duodenum, and the second portion of the duodenum.
8. The inspection goes beyond the second part of the duodenum and may include the jejunum, but not the ileum.
9. If any suspicious areas are identified, the provider introduces scissors or biopsy forceps through the endoscope to collect one or more biopsy samples.
10. The collected tissue samples are sent to the laboratory for further examination.
11. Once the procedure is complete, the provider withdraws the endoscope.

4. Qualifying circumstances

CPT 44361 is performed on patients who require an examination of their small intestines beyond the second part of the duodenum, excluding the ileum. This procedure is typically done to investigate abnormalities or collect biopsy samples for further analysis. It is important to note that the provider must document the medical necessity for performing this procedure.

5. When to use CPT code 44361

CPT code 44361 should be used when a healthcare provider performs an endoscopic examination of the small intestines beyond the second part of the duodenum, excluding the ileum, and collects one or more biopsy samples. It is important to review the documentation to determine if additional services were performed that may require reporting a different code.

6. Documentation requirements

To support a claim for CPT 44361, the healthcare provider must document the following information:

• Reason for performing the procedure and medical necessity
• Details of the endoscopic examination, including the extent of the examination beyond the second part of the duodenum
• Number of biopsy samples collected
• Any additional services performed during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 44361, ensure that the procedure meets the criteria outlined in the official description. It is important to review the documentation to determine if any additional services were performed that may require reporting a different code. It is also essential to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 44361 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A gastroenterologist performs a small intestinal endoscopy beyond the second part of the duodenum, excluding the ileum, and collects multiple biopsy samples for further examination.
2. A general surgeon utilizes an endoscope to examine the small intestines beyond the second part of the duodenum, excluding the ileum, and collects a single biopsy sample for analysis.
3. An interventional radiologist performs a small intestinal endoscopy beyond the second part of the duodenum, excluding the ileum, and collects multiple biopsy samples to aid in the diagnosis of a patient’s condition.
4. A pediatric gastroenterologist conducts a small intestinal endoscopy beyond the second part of the duodenum, excluding the ileum, and collects a single biopsy sample to investigate a child’s gastrointestinal symptoms.
5. An oncologist performs a small intestinal endoscopy beyond the second part of the duodenum, excluding the ileum, and collects multiple biopsy samples to assess the presence of cancerous cells.
6. A gastrointestinal surgeon utilizes an endoscope to examine the small intestines beyond the second part of the duodenum, excluding the ileum, and collects a single biopsy sample to evaluate a patient’s inflammatory bowel disease.