Enteroscopy
A new definition and instructions for reporting antegrade transoral small intestine endoscopy (i.e., enteroscopy) have been added to the section guidelines. Enteroscopy is defined by the most distal segment of small intestine that is examined; coding does not reflect the technology used to perform the examination.
Codes in the 44360 family for enteroscopy, not including ileum (44360–44373), are endoscopic procedures to visualize the esophagus through the jejunum using an antegrade approach. Codes in the 44376 family for enteroscopy, including ileum (44376–44379), are endoscopic procedures to visualize the esophagus through the ileum using an antegrade approach.
If an endoscope cannot be advanced at least 50 cm beyond the pylorus, see the appropriate code in the EGD family (43233, 43235–43259, 43266, 43270). If an endoscope can be passed at least 50 cm beyond pylorus, but only into jejunum, see the appropriate code in the enteroscopy, not including ileum family (44360–44373).
To report retrograde examination of small intestine via anus or colon stoma, use 44799, Unlisted procedure, small intestine.
There were no changes to the language of the individual CPT codes.
Ileoscopy
New codes have been added to the ileoscopy family for transendoscopic balloon dilation and stent placement.
| CPT Code | Short Description | Summary of Changes |
| 44380 | Ileoscopy | Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).” |
| 44382 | Biopsy | No change |
| 44381 | Balloon dilation | Report new code 44381 with modifier 59 for each additional stricture dilated. Not separately reportable with stent placement code 44384 for the same lesion. Use 74360 if fluoroscopic guidance is performed. |
| 44384 | Stent placement | Code 44383 has been deleted. New code 44384 includes pre- and post-dilation and guide wire passage. Not separately reportable with dilation code 44381. Use 74360 if fluoroscopic guidance is performed. |
Pouchoscopy
New section guidelines will instruct users to report pouch endoscopy codes for endoscopic examination of a patient who has undergone resection of colon with ileo-anal anastomosis (e.g., J pouch). Language changes to the pouchoscopy base and biopsy codes are editorial in nature.
| CPT Code | Short Description | Summary of Changes |
| 44385 | Pouchoscopy | Editorial: Terminology updated to include Kock pouch and ileal reservoir [S or J] as examples. “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).” |
| 44386 | Biopsy | No change |
Unlisted Procedures
A new code has been developed and one revised to distinguish unlisted procedure of the colon from unlisted procedure of the small intestine and unlisted procedure of the rectum.
| CPT Code | Short Description | Summary of Changes |
| 44799 | Unlisted procedure, small intestine | Specifies unlisted procedure of small intestine. |
| 45399 | Unlisted procedure, colon | New code for unlisted procedures of the colon. Note: the CPT Errata indicates code 45399 does not include moderate sedation. The moderate sedation bullseye symbol for code 45399 was placed in the CPT 2015 book in error. |