How To Use CPT Code 44363

CPT 44363 describes the procedure for small intestinal endoscopy, specifically enteroscopy beyond the second portion of the duodenum, excluding the ileum, with the removal of foreign bodies. 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 44363?

CPT 44363 is used to describe a specific procedure involving the examination of a portion of the small intestine using an endoscope. The procedure includes the first and second parts of the duodenum and extends into the jejunum, but does not include the ileum. The purpose of this procedure is to locate and remove foreign bodies that may obstruct or damage the intestines.

2. Official Description

The official description of CPT code 44363 is: ‘Small intestinal endoscopy, enteroscopy beyond the second portion of the duodenum, not including ileum; with removal of foreign body(s).’ This code specifically refers to the use of an endoscope to examine the small intestine beyond the second part of the duodenum, excluding the ileum, with the additional procedure of removing any foreign bodies that are found.

3. Procedure

1. The procedure begins with the patient being appropriately prepped and anesthetized.
2. The healthcare provider places a plastic mouthpiece, also known as a bite block, to keep the patient’s mouth open.
3. A thin, flexible endoscope with surgical instruments is inserted through the mouthpiece and advanced towards the stomach as the patient swallows the scope.
4. The provider guides the scope through the stomach and into the first portion of the small intestine, known as the duodenum.
5. A small camera attached to the endoscope sends images to a TV monitor, allowing the provider to inspect the mucosal lining of the esophagus, stomach, upper portion of the duodenum, and the second portion of the duodenum.
6. The provider then continues the examination beyond the second part of the duodenum, potentially including the entire jejunum, but excluding the ileum.
7. If any foreign bodies are identified, the provider uses grasping forceps or another instrument to seize and remove them through the endoscope.
8. Once the procedure is complete, the provider removes all instruments and withdraws the endoscope.

4. Qualifying circumstances

CPT 44363 is performed when there is a need to examine the small intestine beyond the second part of the duodenum, excluding the ileum, and remove any foreign bodies that may be present. This procedure is typically performed when there is a concern that swallowed objects may obstruct or cause damage to the intestines. It is important to note that this procedure requires the use of an endoscope and should be performed by a qualified healthcare provider.

5. When to use CPT code 44363

CPT code 44363 should be used when the healthcare provider performs a small intestinal endoscopy, specifically enteroscopy beyond the second portion of the duodenum, excluding the ileum, with the additional procedure of removing foreign bodies. This code should be used when the examination extends into the jejunum but does not include the ileum. It is important to accurately document the specific details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 44363, the healthcare provider must document the following information:

• Reason for performing the procedure and the need to examine the small intestine beyond the second part of the duodenum
• Details of the procedure, including the use of an endoscope and the removal of foreign bodies
• Date and duration of the procedure
• Specific findings, such as the location and nature of any foreign bodies
• Any additional procedures or interventions performed during the same session
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 44363, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should involve the examination of the small intestine beyond the second part of the duodenum, excluding the ileum, with the additional procedure of removing foreign bodies. It is also important to follow any additional guidelines or requirements set forth by the payer or coding guidelines. It is recommended to review the documentation thoroughly and accurately code the procedure based on the specific details provided.

8. Historical information

CPT 44363 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 healthcare provider performs a small intestinal endoscopy on a patient who swallowed a foreign object. The provider examines the small intestine beyond the second part of the duodenum, excluding the ileum, and successfully removes the foreign body.
2. During a small intestinal endoscopy, a healthcare provider identifies a foreign body in the jejunum of a patient. The provider uses grasping forceps to remove the object, ensuring the proper functioning of the intestines.
3. A patient presents with symptoms of abdominal pain and discomfort. A healthcare provider performs a small intestinal endoscopy, examining the small intestine beyond the second part of the duodenum, excluding the ileum, and discovers a foreign body causing the symptoms. The provider removes the object, providing relief to the patient.