How To Use CPT Code 44388

CPT 44388 describes the diagnostic procedure of colonoscopy through a stoma, including the collection of specimen(s) by brushing or washing, when performed as a separate procedure. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 44388?

CPT 44388 is used to describe a diagnostic procedure called colonoscopy through a stoma. This procedure involves using a colonoscope, a tubular instrument with a light source and camera, to examine the remaining portion of the colon after a colon removal surgery. The colonoscope is inserted through a colostomy stoma, which is a surgically created passageway into the colon. During the procedure, the healthcare provider looks for signs of recurrent disease, such as cancer, and may collect samples of suspicious tissue for laboratory analysis by brushing or washing the area.

2. Official Description

The official description of CPT code 44388 is: ‘Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).’ It is important to note that CPT code 44388 should not be reported in conjunction with codes 44389 to 44408.

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The healthcare provider passes a lubricated colonoscope into the patient’s stoma.
3. The provider gently guides the scope through the colostomy and into the colon.
4. A puff of air is sent through the scope to expand the folds of tissue, allowing for better observation of the colon lining.
5. If any suspicious tissue is identified, the provider collects samples by brushing the area or irrigating it with warm saline and aspirating the fluid.
6. The collected samples are sent to the laboratory for examination.
7. Once the procedure is complete, the provider removes all instruments and withdraws the colonoscope.

4. Qualifying circumstances

CPT 44388 is performed on patients who have undergone a colon removal surgery and have a colostomy stoma. The procedure is used to examine the remaining portion of the colon and collect samples of suspicious tissue for diagnostic purposes. It is important to note that CPT code 44388 should not be reported in conjunction with codes 44389 to 44408.

5. When to use CPT code 44388

CPT code 44388 should be used when a healthcare provider performs a diagnostic colonoscopy through a stoma, including the collection of specimen(s) by brushing or washing, as a separate procedure. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 44388, the healthcare provider must document the following information:

• Indication for the procedure and the presence of a colostomy stoma
• Details of the colonoscopy procedure, including the use of a colonoscope and the method of specimen collection (brushing or washing)
• Date and duration of the procedure
• Findings during the procedure, including any suspicious tissue or abnormalities
• Documentation of the collected specimens and their submission to the laboratory
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 44388, it is important to ensure that the procedure meets the specific criteria outlined in the code description. CPT code 44388 should not be reported in conjunction with codes 44389 to 44408. It is also important to follow any additional guidelines provided by the payer or coding guidelines.

8. Historical information

CPT code 44388 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2015, with an updated description: ‘Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).’

9. Examples

1. A healthcare provider performs a diagnostic colonoscopy through a colostomy stoma on a patient who previously underwent colon removal surgery. During the procedure, the provider collects samples of suspicious tissue by brushing the area for laboratory analysis.
2. Using a colonoscope, a healthcare provider examines the remaining portion of the colon through a colostomy stoma in a patient with a history of colon removal surgery. The provider identifies a suspicious area and collects a sample by washing the area with warm saline and aspirating the fluid for further analysis.
3. During a diagnostic colonoscopy through a colostomy stoma, a healthcare provider uses a colonoscope to carefully examine the colon lining in a patient who underwent colon removal surgery. The provider identifies a suspicious lesion and collects a sample by brushing the area for laboratory examination.
4. A patient with a colostomy stoma undergoes a diagnostic colonoscopy performed by a healthcare provider. The provider uses a colonoscope to thoroughly examine the remaining portion of the colon and collects samples of suspicious tissue by washing the area with warm saline and aspirating the fluid for analysis.
5. Using a colonoscope, a healthcare provider performs a diagnostic colonoscopy through a colostomy stoma in a patient who previously had colon removal surgery. The provider carefully examines the colon lining and collects samples of suspicious tissue by brushing the area for further evaluation.