How To Use CPT Code 44381

CPT 44381 describes the procedure of ileoscopy with transendoscopic balloon dilation through a stoma. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 44381?

CPT 44381 is used to describe the procedure of ileoscopy with transendoscopic balloon dilation through a stoma. This code is used when a provider inserts a scope via a stoma to examine the ileum of the small intestine and performs balloon dilation through an endoscope.

2. Official Description

The official description of CPT code 44381 is: ‘Ileoscopy, through stoma; with transendoscopic balloon dilation.’

3. Procedure

1. The provider inserts a scope via a stoma to examine the ileum of the small intestine.
2. A balloon catheter is introduced through the endoscope, positioning it in the center of the stricture.
3. The provider inflates the balloon to remove the stricture and deflates it to ensure successful dilation.
4. In some cases, larger balloons may be used for stricture dilation.
5. After the procedure, the provider removes the scope.

4. Qualifying circumstances

CPT 44381 is performed when a patient has an ileostomy, which is a surgically created passage from the ileum to the external surface of the abdomen. This procedure is typically done to divert waste through a stoma. The patient may have an obstruction or stricture in the ileum that requires examination and dilation. It is important to note that CPT 44381 should not be reported in conjunction with CPT codes 44380 and 44384.

5. When to use CPT code 44381

CPT code 44381 should be used when a provider performs ileoscopy with transendoscopic balloon dilation through a stoma. It is appropriate to use this code when the procedure is performed and meets the specific criteria outlined in the official description.

6. Documentation requirements

To support a claim for CPT 44381, the provider must document the following information:

• Patient’s diagnosis and indication for the procedure
• Details of the procedure, including the use of a scope, balloon catheter, and any additional instruments
• Date and duration of the procedure
• Specific location of the stricture and the success of the dilation
• Any complications or additional interventions performed
• Provider’s signature

7. Billing guidelines

When billing for CPT 44381, ensure that the procedure meets the specific criteria outlined in the official description. It is important to note that CPT 44381 should not be reported in conjunction with CPT codes 44380 and 44384. If fluoroscopic guidance is performed during the procedure, use CPT code 74360. If multiple strictures are dilated during the same session, report CPT 44381 with modifier 59 for each additional stricture dilated.

8. Historical information

CPT 44381 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Examples

1. A provider performs ileoscopy with transendoscopic balloon dilation through a stoma to remove a stricture in the ileum of a patient with Crohn’s disease.
2. During the procedure, the provider uses a scope and introduces a balloon catheter to dilate a stricture in the ileum of a patient with an ileostomy.
3. A patient with a history of bowel obstruction undergoes ileoscopy with transendoscopic balloon dilation through a stoma to relieve a stricture in the ileum.
4. The provider performs ileoscopy with transendoscopic balloon dilation through a stoma to treat a patient with an obstructed ileum due to scar tissue.
5. A patient with a stoma undergoes ileoscopy with transendoscopic balloon dilation to address a stricture in the ileum causing bowel obstruction.
6. During the procedure, the provider uses a scope and a balloon catheter to dilate a stricture in the ileum of a patient with an ileostomy.
7. A provider performs ileoscopy with transendoscopic balloon dilation through a stoma to relieve a stricture in the ileum of a patient with inflammatory bowel disease.
8. The provider uses an endoscope and a balloon catheter to dilate a stricture in the ileum of a patient with an ileostomy during the procedure.
9. A patient with a history of bowel strictures undergoes ileoscopy with transendoscopic balloon dilation through a stoma to address an obstructed ileum.
10. During the procedure, the provider examines the ileum of a patient with an ileostomy and performs balloon dilation to relieve a stricture causing bowel obstruction.