How To Use CPT Code 44377

CPT 44377 describes the procedure for small intestinal endoscopy, specifically enteroscopy beyond the second portion of the duodenum, including the ileum, with biopsy. 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 44377?

CPT 44377 is a code used to describe a specific procedure known as small intestinal endoscopy. This procedure involves the use of a lighted endoscope to visually examine the upper gastrointestinal tract, from the esophagus to the ileum. The provider may also perform biopsies of suspicious areas for further analysis.

2. Official Description

The official description of CPT code 44377 is: ‘Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple.’

3. Procedure

1. The patient is taken to the operating room and placed on the surgical table lying on their back.
2. The provider sprays the patient’s mouth and throat with a local anesthetic to numb the area and reduce the gag reflex.
3. A plastic mouthpiece, or bite block, is inserted to keep the patient’s mouth open.
4. The provider inserts a thin flexible fiberoptic endoscope through the mouthpiece and advances it through the esophagus and towards the stomach.
5. The provider guides the scope under direct vision through the stomach into the first portion of the small bowel, known as the duodenum.
6. A small camera on the endoscope sends magnified images to a TV monitor, allowing the provider to examine the intestinal lining and analyze the interior structure.
7. The provider inspects the mucosal lining of the esophagus, stomach, duodenum, jejunum, and ileum for any suspicious lesions.
8. If any suspicious areas are identified, the provider uses biopsy forceps passed through the channel in the endoscope to grasp and remove a portion of abnormal tissue for further examination.
9. The tissue samples are sent to the laboratory for histopathologic examination.
10. Upon completion, the provider withdraws the scope, carefully reexamining the digestive tract as they remove the instrument.
11. The patient is released after a short recovery period.

4. Qualifying circumstances

CPT 44377 is performed on patients who require a visual examination of the small intestine beyond the second portion of the duodenum, including the ileum. This procedure is typically done to investigate and diagnose any abnormalities or suspicious lesions in the small intestine. It is important to note that CPT 44377 should not be reported in conjunction with other specific codes related to small intestinal endoscopy.

5. When to use CPT code 44377

CPT code 44377 should be used when the provider performs a small intestinal endoscopy that goes beyond the second portion of the duodenum and includes the ileum. This code is specifically for procedures that involve biopsies of single or multiple suspicious areas in the small intestine. It is important to review the documentation to determine if this code is appropriate based on the additional services performed.

6. Documentation requirements

To support a claim for CPT 44377, the provider must document the following information:

• Reason for performing the small intestinal endoscopy
• Specific areas of the small intestine examined
• Details of any suspicious lesions or abnormalities identified
• Number of biopsies performed and the specific areas from which the tissue samples were obtained
• Documentation of the histopathologic examination of the tissue samples

7. Billing guidelines

When billing for CPT 44377, it is important to ensure that the procedure performed meets the criteria outlined in the code description. This includes performing the endoscopy beyond the second portion of the duodenum and including the ileum, as well as performing biopsies of single or multiple suspicious areas. It is also important to note that CPT 44377 should not be reported in conjunction with other specific codes related to small intestinal endoscopy. Review the documentation and guidelines carefully to ensure accurate reporting.

8. Historical information

CPT 44377 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 patient undergoes a small intestinal endoscopy beyond the second portion of the duodenum, including the ileum, with biopsies taken from suspicious areas.
2. A provider performs a small intestinal endoscopy to examine the mucosal lining of the esophagus, stomach, duodenum, jejunum, and ileum, and takes biopsies of suspicious lesions.
3. During a small intestinal endoscopy, the provider identifies abnormal tissue in the ileum and performs a biopsy for further examination.
4. A patient undergoes a small intestinal endoscopy with biopsies of multiple suspicious areas in the small intestine.
5. A provider performs a small intestinal endoscopy beyond the second portion of the duodenum, including the ileum, and takes biopsies of single suspicious areas.
6. During a small intestinal endoscopy, the provider identifies a suspicious lesion in the jejunum and performs a biopsy for further analysis.
7. A patient undergoes a small intestinal endoscopy with biopsies of suspicious areas in the duodenum and ileum.