Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a spiral enteroscopy procedure. Are there separate CPT® codes for spiral enteroscopy and other enteroscopy procedures?

Oklahoma Subscriber

Answer: Enteroscopy is a procedure used by your gastroenterologist to view the small intestine. Another method used to visualize the small intestine is to use capsule endoscopy. However with capsule endoscopy, your gastroenterologist will only be able to visualize the small intestine and will not be able to perform any additional procedures, like taking a biopsy specimen.

Your gastroenterologist might use different techniques for enteroscopy. The three different techniques used by gastroenterologists for enteroscopy include:

• Single balloon enteroscopy
• Double balloon enteroscopy
• Spiral enteroscopy

Note that there are no separate CPT® codes for the different techniques of enteroscopy your gastroenterologist might use. Instead, while choosing the right code to report you will have to concentrate on the following guidelines:

The approach used -- The most common approach is through the mouth (antegrade approach) although sometimes your gastroenterologist might view the distal portions of the ileum using a retrograde approach through the rectum.

The extent to which the small intestine was visualized

The purpose of the procedure (such as visualization, biopsy, removal of a lesion using a snare, control of bleeding, etc)

Example: If your gastroenterologist used a spiral enteroscopy procedure to visualize the small intestine through an antegrade approach, then you can use 44360 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) if your gastroenterologist did not visualize the ileum and 44376 (...including ileum...) if the entire small intestine including the ileum was visualized.

Suppose during the procedure your gastroenterologist took a biopsy specimen, then you have to report the procedure using 44361 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple) or 44377 (...including ileum...) depending on the extent to which the scope was advanced.

Instead, if your gastroenterologist used a retrograde approach for the enteroscopy procedure, you will have to use the unlisted procedure code 44799 (Unlisted procedure, intestine) as there is no separate CPT® code to report the procedure done using a retrograde approach.