Gastroenterology Coding Alert

Question: Which codes can we use for an ileoscopy through a stoma with balloon dilation?

Connecticut Subscriber

Answer: The code for the ileoscopy through stoma is 44380 (Ileoscopy, through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Option 1: Although you won't find any specific CPT code for reporting a balloon dilation in the small bowel and stoma, you can try using 44799 (Unlisted procedure, intestine) to report the procedure to both Medicare carriers and commercial insurers.

Heads up: You should list 44380 first on your claim, followed by 44799. Some payers may require the use of modifier 51 (Multiple procedures) with 44799.

Option 2: Another option for coding the balloon dilation is to attach modifier 22 (Increased procedural services) to 44380. You should contact your local Medicare carrier or commercial insurer to determine what coding method they prefer.
Keep in mind: Regardless of how you handle the balloon dilation's coding , you must have adequate documentation including the operative report and a separate statement describing the procedure. Your gastroenterologist should include a separate statement that explains why the balloon dilation is above and beyond the usual endoscopic service described in the CPT code. You should not use another CPT code that defines balloon dilation with a different approach or in a different part of the gastrointestinal tract.