How To Use CPT Code 44392

CPT 44392 describes the procedure of colonoscopy through a stoma with the removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 44392?

CPT 44392 is used to describe a specific procedure involving a colonoscopy through a stoma. During this procedure, a qualified healthcare provider uses a colonoscope, a tubular instrument with a light source and camera, to examine the remaining portion of the colon after a previous colon removal surgery. The provider inserts the scope through a colostomy stoma, which is a surgically created opening on the skin that provides access to the colon. Using hot biopsy forceps, the provider removes abnormal masses or growths for further analysis in a laboratory.

2. Official Description

The official description of CPT code 44392 is: ‘Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.’

3. Procedure

1. The healthcare provider ensures that the patient is appropriately prepped and anesthetized for the procedure.
2. Using a lubricated colonoscope, the provider gently passes the instrument through the colostomy stoma and into the colon.
3. A puff of air is sent through the scope to expand the tissue folds, allowing for a thorough examination of the entire colon.
4. The provider carefully inspects the colon for any abnormal masses, tumors, polyps, or lesions.
5. If any abnormal growths are identified, the provider uses hot biopsy forceps to grasp, excise, and cauterize the tissue to prevent bleeding.
6. The removed specimens are sent to a laboratory for further analysis.
7. Once the procedure is complete, the provider removes all instruments and withdraws the colonoscope.

4. Qualifying circumstances

CPT 44392 is performed when a patient has a colostomy stoma and requires a colonoscopy for the removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps. The procedure is typically performed by a qualified healthcare provider who has the necessary expertise and training in performing colonoscopies.

5. When to use CPT code 44392

CPT code 44392 should be used when a colonoscopy is performed through a stoma and involves the removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps. It is important to note that CPT code 44392 should not be reported in conjunction with CPT code 44388.

6. Documentation requirements

To support a claim for CPT 44392, the healthcare provider must document the following information:

• Confirmation of the presence of a colostomy stoma
• Details of the procedure, including the use of a colonoscope and hot biopsy forceps
• Description of the tumor(s), polyp(s), or other lesion(s) removed
• Date and duration of the procedure
• Any additional relevant findings or observations
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 44392, ensure that the procedure meets the specific criteria outlined in the code description. It is important to note that CPT code 44392 should not be reported in conjunction with CPT code 44388. Additional tips for accurate billing include reviewing the operative note for supporting details and specifying whether the stoma is a colostomy or an ileostomy.

8. Historical information

CPT code 44392 was added to the Current Procedural Terminology system on January 1, 1990. The code was later updated on January 1, 2015, to include the option of using bipolar cautery for the removal of tumor(s), polyp(s), or other lesion(s) through a stoma.

9. Examples

1. A gastroenterologist performing a colonoscopy through a colostomy stoma and removing a polyp using hot biopsy forceps.
2. A general surgeon conducting a colonoscopy through a stoma and excising a tumor using hot biopsy forceps.
3. An oncologist performing a colonoscopy through a colostomy stoma and removing multiple lesions using hot biopsy forceps.
4. A colorectal surgeon conducting a colonoscopy through a stoma and removing a large polyp using hot biopsy forceps.
5. A gastroenterologist performing a colonoscopy through a colostomy stoma and removing a small tumor using hot biopsy forceps.
6. A general surgeon conducting a colonoscopy through a stoma and excising a polyp using hot biopsy forceps.
7. An oncologist performing a colonoscopy through a colostomy stoma and removing a lesion using hot biopsy forceps.
8. A colorectal surgeon conducting a colonoscopy through a stoma and removing multiple polyps using hot biopsy forceps.
9. A gastroenterologist performing a colonoscopy through a colostomy stoma and removing a tumor using hot biopsy forceps.
10. A general surgeon conducting a colonoscopy through a stoma and excising a lesion using hot biopsy forceps.