How To Use CPT Code 44389

CPT 44389 describes the procedure of colonoscopy through a stoma with biopsy, either single or multiple. 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 44389?

CPT 44389 is used to describe the examination of the remaining colon using an endoscope passed through a previously created stoma. During this procedure, the healthcare provider may perform a biopsy on suspicious areas of abnormal mucosa or tissue and send the samples to the laboratory for further examination.

2. Official Description

The official description of CPT code 44389 is: ‘Colonoscopy through stoma; with biopsy, single or multiple.’

3. Procedure

1. The patient is taken to the operating room and positioned on the surgical table.
2. The healthcare provider inserts a lubricated endoscope into the patient’s stoma.
3. Gently guiding the scope through the colostomy and into the colon, the provider uses a puff of air to expand the tissue folds for a thorough examination.
4. If any areas of abnormal mucosa or tissue are identified, the provider uses forceps through the endoscope to collect tissue samples for biopsy.
5. The collected samples are sent to the laboratory for histopathologic examination.
6. After completing the procedure, the provider removes the scope, reexamines the area, and allows the patient to recover before discharge.

4. Qualifying circumstances

CPT 44389 is performed when a patient has a previously created stoma, typically due to conditions such as colon cancer or Crohn’s disease. The procedure involves the examination of the colon using an endoscope passed through the stoma, with the option to perform biopsies on suspicious areas. The patient may or may not be sedated during the procedure.

5. When to use CPT code 44389

CPT code 44389 should be used when a healthcare provider performs a colonoscopy through a stoma and performs biopsies on suspicious areas of abnormal mucosa or tissue. It is important to note that CPT code 44389 should not be reported in conjunction with CPT code 44403 for the same lesion or with CPT code 44388.

6. Documentation requirements

To support a claim for CPT code 44389, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the colonoscopy procedure through the stoma
• Specific areas of abnormal mucosa or tissue identified
• Number of biopsies performed
• Documentation of the samples sent to the laboratory for histopathologic examination

7. Billing guidelines

When billing for CPT code 44389, ensure that the procedure involves a colonoscopy through a stoma with biopsy. It is important to follow the guidelines and not report CPT code 44389 in conjunction with CPT code 44403 for the same lesion or with CPT code 44388.

8. Historical information

CPT code 44389 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 patient with a previously created stoma undergoes a colonoscopy through the stoma, and the healthcare provider performs a biopsy on a suspicious area of abnormal tissue.
2. During a colonoscopy through a stoma, the healthcare provider identifies multiple areas of abnormal mucosa and performs biopsies on each suspicious area.
3. A patient with Crohn’s disease undergoes a colonoscopy through a stoma, and the healthcare provider collects tissue samples for biopsy from areas of inflammation.
4. During a colonoscopy through a stoma, the healthcare provider identifies a polyp and performs a biopsy to determine if it is cancerous.
5. A patient with a history of colon cancer undergoes a colonoscopy through a stoma, and the healthcare provider performs biopsies on areas of the colon to monitor for recurrence.
6. During a colonoscopy through a stoma, the healthcare provider identifies an area of abnormal tissue and performs a biopsy to evaluate for inflammatory bowel disease.
7. A patient with a colostomy undergoes a colonoscopy through the stoma, and the healthcare provider performs a biopsy on a suspicious area of ulceration.
8. During a colonoscopy through a stoma, the healthcare provider identifies a mass and performs a biopsy to determine if it is benign or malignant.
9. A patient with a history of polyps undergoes a colonoscopy through a stoma, and the healthcare provider performs biopsies on any suspicious areas to check for recurrence.
10. During a colonoscopy through a stoma, the healthcare provider identifies areas of abnormal mucosa and performs biopsies to evaluate for inflammatory changes.