How To Use CPT Code 44364

CPT 44364 describes the procedure of 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 44364?

CPT 44364 is used to describe a specific procedure known as small intestinal endoscopy. This procedure involves the use of an endoscope to examine the intestines for abnormalities, going beyond the second part of the duodenum but not including the ileum. Additionally, during this procedure, the provider may remove one or more tumors, polyps, or other types of lesions using a snare technique.

2. Official Description

The official description of CPT code 44364 is: ‘Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.’

3. Procedure

1. The provider begins by appropriately prepping and anesthetizing the patient.
2. A plastic mouthpiece, also known as a bite block, is placed to keep the patient’s mouth open.
3. The provider inserts a thin, flexible, fiberoptic endoscope through the mouthpiece.
4. As the patient swallows the scope, the provider advances it towards the stomach.
5. The provider guides the scope through the stomach and into the first portion of the small bowel, known as the duodenum.
6. If necessary, the provider may use an incision in the abdomen to assist with the endoscopy.
7. A small camera attached to the endoscope sends images to a TV monitor, allowing the provider to visualize the intestinal lining.
8. The provider inspects the mucosal linings of the esophagus, stomach, upper portion of the duodenum, and the second portion of the duodenum.
9. The inspection goes beyond the second part of the duodenum and may include all of the jejunum, but not the ileum.
10. If polyps, tumors, or other lesions are identified, the provider introduces a snare device through the endoscope.
11. Using the snare device, the provider removes the identified polyps, tumors, or lesions.
12. Once the procedure is complete, the provider withdraws the endoscope.

4. Qualifying circumstances

CPT 44364 is performed on patients who require small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum. This procedure is typically indicated when there is a need to remove tumors, polyps, or other types of lesions using a snare technique.

5. When to use CPT code 44364

CPT code 44364 should be used when a provider performs a small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum, and removes tumors, polyps, or other lesions using a snare technique. It is important to note that this code should not be used if the scope does not go at least 50 cm past the pylorus, which is the sphincter between the stomach and the duodenum.

6. Documentation requirements

To support a claim for CPT 44364, the provider must document the following information:

• Patient’s medical history and reason for the procedure
• Details of the small intestinal endoscopy, including the specific areas examined
• Description of any tumors, polyps, or lesions identified
• Documentation of the snare technique used for removal
• Any additional procedures or interventions performed during the same session
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 44364, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The provider should also review the documentation to determine if any additional services were performed that may warrant separate reporting. It is crucial to accurately report the procedure and any associated modifiers to ensure proper reimbursement.

8. Historical information

CPT 44364 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 portion of the duodenum, excluding the ileum, and removes a polyp using a snare technique.
2. A general surgeon conducts a small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum, and removes multiple tumors using a snare technique.
3. An interventional radiologist performs a small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum, and removes a lesion using a snare technique.
4. A gastroenterologist conducts a small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum, and removes a polyp and a tumor using a snare technique.
5. A colorectal surgeon performs a small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum, and removes a polyp and a lesion using a snare technique.
6. An oncologist conducts a small intestinal endoscopy beyond the second portion of the duodenum, excluding the ileum, and removes multiple tumors and polyps using a snare technique.