How To Use CPT Code 44365

CPT 44365 describes a specific endoscopic procedure used to examine the small intestines and remove tumors, polyps, or other lesions using hot biopsy forceps or bipolar cautery. 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 44365?

CPT 44365 is a code that represents a specific endoscopic procedure used to examine the small intestines beyond the second part of the duodenum, but not including the ileum. During this procedure, the healthcare provider uses hot biopsy forceps or bipolar cautery to remove tumors, polyps, or other lesions that may be present in the intestines.

2. Official Description

The official description of CPT code 44365 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 hot biopsy forceps or bipolar cautery.’

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 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. If any polyps, tumors, or lesions are identified, the provider introduces hot biopsy forceps or a bipolar cautery device through the endoscope.
9. Using the hot biopsy forceps or bipolar cautery, the provider removes and cauterizes the polyps, tumors, or lesions using high-frequency electrical current.
10. Once the procedure is complete, the provider withdraws the endoscope.

4. Qualifying circumstances

CPT 44365 is performed on patients who require an endoscopic examination of the small intestines beyond the second part of the duodenum, but not including the ileum. The procedure is typically done to remove tumors, polyps, or other lesions using hot biopsy forceps or bipolar cautery. It is important to note that this procedure is specific to the small intestines and does not include examination or treatment of other parts of the gastrointestinal tract.

5. When to use CPT code 44365

CPT code 44365 should be used when a healthcare provider performs an endoscopic examination of the small intestines beyond the second part of the duodenum, but not including the ileum. This code is specifically for cases where the provider removes tumors, polyps, or other lesions using hot biopsy forceps or bipolar cautery. It is important to review the documentation and ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT code 44365, the healthcare provider must document the following information:

• Patient’s medical history and reason for the procedure
• Details of the endoscopic examination, including the specific parts of the small intestines examined
• Description of any tumors, polyps, or lesions identified
• Method used for removal (hot biopsy forceps or bipolar cautery)
• Documentation of any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 44365, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The provider should document the necessary information to support the claim, including the details of the examination and the removal of tumors, polyps, or lesions. It is also important to review any additional guidelines or requirements from the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT code 44365 was added to the Current Procedural Terminology system on January 1, 1994. There have been no updates or changes to the code since its addition.

9. Examples

1. A gastroenterologist performs an endoscopic examination of the small intestines beyond the second part of the duodenum and removes a tumor using hot biopsy forceps.
2. A general surgeon performs an endoscopic procedure to remove multiple polyps from the small intestines using bipolar cautery.
3. An interventional radiologist performs an endoscopic examination of the small intestines and removes a lesion using hot biopsy forceps.
4. A gastroenterologist performs an endoscopic examination of the small intestines and removes a polyp using bipolar cautery.
5. A colorectal surgeon performs an endoscopic procedure to remove a tumor from the small intestines using hot biopsy forceps.
6. A gastroenterologist performs an endoscopic examination of the small intestines and removes multiple polyps using bipolar cautery.
7. An interventional radiologist performs an endoscopic procedure to remove a lesion from the small intestines using hot biopsy forceps.