How To Use CPT Code 44391

CPT 44391 describes the examination and control of bleeding in the remaining portion of the colon after a colon removal procedure, using a colonoscope inserted through a colostomy stoma. 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 44391?

CPT 44391 can be used to describe the examination and control of bleeding in the colon through a colostomy stoma. This code is used when a provider uses a colonoscope to examine the remaining portion of the colon after a previous colon removal procedure and identifies and repairs areas of internal bleeding.

2. Official Description

The official description of CPT code 44391 is: ‘Colonoscopy through stoma; with control of bleeding, any method.’

3. Procedure

1. The provider inserts a lubricated colonoscope into the patient’s colostomy stoma.
2. The provider gently guides the scope through the colostomy and into the remaining portion of the colon.
3. A puff of air is sent through the scope to expand the folds of tissue and facilitate examination.
4. The provider identifies the area of bleeding and applies cautery or uses another method to stop the bleeding.
5. All instruments are removed, and the colonoscope is withdrawn.

4. Qualifying circumstances

Patients eligible for CPT 44391 are those who have undergone a colon removal procedure and have a colostomy stoma. The procedure is performed to examine the remaining portion of the colon and control bleeding. It is important to note that CPT 44391 should not be reported in conjunction with CPT 44404 for the same lesion or with CPT 44388.

5. When to use CPT code 44391

CPT code 44391 should be used when a provider performs a colonoscopy through a colostomy stoma to examine the remaining portion of the colon and control bleeding. 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 44391, the provider must document the following information:

• Details of the patient’s previous colon removal procedure and the presence of a colostomy stoma
• Date and time of the procedure
• Specific method used to control bleeding
• Any additional procedures performed during the colonoscopy, such as biopsies or lesion removal
• Any complications or adverse events encountered
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 44391, ensure that the procedure meets the specific criteria outlined in the code description. It is important to note that CPT 44391 should not be reported in conjunction with CPT 44404 for the same lesion or with CPT 44388. Additional tips for accurate billing include reviewing the operative note for supporting details and determining the type of stoma (colostomy or ileostomy) created during the previous procedure.

8. Historical information

CPT 44391 was added to the Current Procedural Terminology system on January 1, 1990. There have been changes to the code over the years, including updates in 2002 and 2015 to clarify the description and specify the methods of bleeding control.

9. Examples

1. A provider performs a colonoscopy through a colostomy stoma to examine the remaining portion of the colon and control bleeding in a patient who previously underwent a colon removal procedure.
2. During a colonoscopy through a colostomy stoma, a provider identifies and repairs areas of internal bleeding in the remaining portion of the colon in a patient with a history of colon removal.
3. A patient with a colostomy stoma undergoes a colonoscopy to examine the remaining portion of the colon and control bleeding, performed by a provider.
4. A provider uses a colonoscope inserted through a colostomy stoma to examine the remaining portion of the colon and apply cautery to control bleeding in a patient who underwent a previous colon removal procedure.
5. During a colonoscopy through a colostomy stoma, a provider identifies and repairs areas of internal bleeding in the remaining portion of the colon in a patient with a history of colon removal.
6. A patient with a colostomy stoma undergoes a colonoscopy to examine the remaining portion of the colon and control bleeding, performed by a provider.
7. A provider uses a colonoscope inserted through a colostomy stoma to examine the remaining portion of the colon and apply cautery to control bleeding in a patient who underwent a previous colon removal procedure.
8. During a colonoscopy through a colostomy stoma, a provider identifies and repairs areas of internal bleeding in the remaining portion of the colon in a patient with a history of colon removal.
9. A patient with a colostomy stoma undergoes a colonoscopy to examine the remaining portion of the colon and control bleeding, performed by a provider.
10. A provider uses a colonoscope inserted through a colostomy stoma to examine the remaining portion of the colon and apply cautery to control bleeding in a patient who underwent a previous colon removal procedure.