Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed a double balloon enteroscopy wherein he entered the small bowel during a colonoscopy. What code do I report to bill out the procedure he performed?

Massachusetts Subscriber

Answer:

Enteroscopy is a procedure used by your gastroenterologist to view the small intestine. 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. You will only have to report the same set of codes irrespective of the technique used for the procedure.

If your gastroenterologist performed the double balloon enteroscopy using the oral approach, you will have to report 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.

But, since your gastroenterologist approached the small intestine through the rectum, 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.