How To Use CPT Code 44401

CPT 44401 describes the procedure of colonoscopy through a stoma, specifically involving the ablation of tumor(s), polyp(s), or other lesion(s). 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 44401?

CPT 44401 is used to describe a specific type of colonoscopy procedure. It involves the insertion of a colonoscope through a stoma, which is an artificial opening in the patient’s skin. During this procedure, the healthcare provider observes and destroys any tumors, polyps, or other abnormal changes in the intestinal tissue. It is important to note that CPT 44401 should not be reported in conjunction with CPT 44405 for the same lesion, or with CPT 44388.

2. Official Description

The official description of CPT code 44401 is: ‘Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed).’ It is important to remember the notes associated with this code, which state not to report 44401 with 44405 for the same lesion, and not to report 44401 with 44388.

3. Procedure

1. The healthcare provider begins by appropriately prepping and anesthetizing the patient.
2. Using a colonoscope, the provider inserts it through the stoma to visualize the colon and identify any tumors, polyps, or other lesions.
3. If necessary, the provider may perform predilation and post dilation at the site of the lesion.
4. During the procedure, the provider performs the ablation of one or more lesions, using techniques such as removal of tissue or destruction of its function.
5. If required, the provider may also insert a guide wire to assist in positioning the catheter or other items.
6. Once the procedure is complete, the provider removes the colonoscope.

4. Qualifying circumstances

CPT 44401 is performed on patients who have an artificial opening in their skin called a stoma. The procedure is used to visualize the colon and ablate any tumors, polyps, or other lesions present. The provider may also perform predilation, post dilation, and guide wire passage if necessary. It is important to note that CPT 44401 should not be reported with CPT 44405 for the same lesion, or with CPT 44388.

5. When to use CPT code 44401

CPT code 44401 should be used when a healthcare provider performs a colonoscopy through a stoma and ablates tumor(s), polyp(s), or other lesion(s). It is important to follow the guidelines and not report CPT 44401 with CPT 44405 for the same lesion, or with CPT 44388.

6. Documentation requirements

To support a claim for CPT 44401, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the procedure, including the use of a colonoscope and ablation techniques
• Date and duration of the procedure
• Specific lesions treated during the procedure
• Any additional procedures performed, such as predilation, post dilation, or guide wire passage
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 44401, ensure that the procedure involves the ablation of tumor(s), polyp(s), or other lesion(s) through a colonoscopy performed via a stoma. It is important not to report CPT 44401 with CPT 44405 for the same lesion, or with CPT 44388. Follow the appropriate coding guidelines and modifiers if necessary.

8. Historical information

CPT 44401 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 healthcare provider performs a colonoscopy through a stoma and ablates a tumor in the patient’s colon.
2. During a colonoscopy through a stoma, the provider identifies and ablates multiple polyps in the patient’s colon.
3. A patient with a stoma undergoes a colonoscopy, during which the provider performs the ablation of a lesion in the colon.
4. Using a colonoscope through a stoma, the provider identifies and ablates a tumor in the patient’s colon.
5. During a colonoscopy through a stoma, the provider performs the ablation of multiple lesions in the patient’s colon.
6. A healthcare provider performs a colonoscopy through a stoma and ablates a polyp in the patient’s colon.
7. During a colonoscopy through a stoma, the provider identifies and ablates a tumor and a polyp in the patient’s colon.
8. A patient with a stoma undergoes a colonoscopy, during which the provider performs the ablation of multiple lesions in the colon.
9. Using a colonoscope through a stoma, the provider identifies and ablates a lesion in the patient’s colon.
10. During a colonoscopy through a stoma, the provider performs the ablation of a tumor and multiple polyps in the patient’s colon.