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CPT 44361: Endoscopic Examination of Proximal Small Intestine with Biopsy

CPT code 44361 represents a diagnostic endoscopic procedure of the proximal small intestine in which the endoscope advances beyond the second portion of the duodenum but does not reach the ileum, with one or more biopsy specimens obtained. This code captures clinically important evaluations for unexplained upper abdominal pain, malabsorption, bleeding, or suspected small-bowel pathology when tissue sampling is required. Nationally, accurate coding of this procedure affects clinical documentation, facility and professional billing, and aggregation of utilization for quality measurement.

Key payers referenced in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, common sites of service, and the typical service type represented by the code. The publication also outlines commonly reported modifiers and payer coverage considerations where available. The material is intended to help coding professionals, billing managers, and clinical leaders understand how CPT code 44361 is used in practice, what clinical situations prompt its use, and what benchmarking and policy implications to expect at a national level.

Data not available in the input: associated taxonomies, ICD-10 diagnoses, related codes, and detailed payer-specific reimbursement rates.

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Billing Code Overview

CPT code 44361 describes an endoscopic examination of the small intestine performed with an endoscope that advances past the second portion of the duodenum but does not include the ileum. The procedure includes obtaining one or more biopsy specimens during the endoscopic inspection.

Service type: Diagnostic endoscopy with biopsy of the proximal small intestine (beyond the second portion of the duodenum, excluding ileum)
Typical site of service: Outpatient endoscopy suite or hospital-based endoscopy unit

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CPT 44361: Endoscopic Examination of Proximal Small Intestine with Biopsy

Data not available in the input: associated taxonomies, ICD-10 diagnoses, related codes, and detailed payer-specific reimbursement rates.

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Get alerted when payer policies referencing 44361 are released or updated.

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Billing Code Overview

Service type: Diagnostic endoscopy with biopsy of the proximal small intestine (beyond the second portion of the duodenum, excluding ileum)
Typical site of service: Outpatient endoscopy suite or hospital-based endoscopy unit

Clinical & Coding Specifications

Clinical Context

A 52-year-old patient with several months of intermittent epigastric pain, unexplained iron-deficiency anemia, and intermittent melena is referred for upper small bowel evaluation. The gastroenterologist performs an endoscopic examination using a forward-viewing endoscope that is advanced beyond the second portion of the duodenum (D2) into the proximal jejunum but not to the ileum, evaluates the mucosa for sources of bleeding, inflammation, tumors, or celiac-related changes, and obtains one or more mucosal biopsies for histology and immunohistochemistry. The procedure is typically scheduled electively in an ambulatory endoscopy center or hospital endoscopy suite under moderate sedation or monitored anesthesia care. Pre-procedure workflow includes history and medication reconciliation (anticoagulant management), informed consent, and brief physical assessment; intra-procedure workflow includes topical anesthesia, sedation, endoscopic inspection, targeted biopsy(s), documentation of findings and specimen labeling; post-procedure workflow includes recovery monitoring, discharge instructions, pathology result follow-up, and communication of clinically significant biopsy results to the referring provider and payor as required.

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure	Use when a distinct E/M visit occurs on the same day as the endoscopic procedure and is documented separately.
`52`	Reduced services	Use when the endoscopic procedure is partially reduced or not completed for documented reasons.
`53`	Discontinued procedure	Use when the procedure is started but terminated due to patient condition or anatomic difficulty before completion.
`59`	Distinct procedural service	Use to indicate a separate, unrelated procedure or service performed on the same day.
`62`	Two surgeons	Use when two surgeons with different specialties are present and both perform distinct portions of the procedure.
`76`	Repeat procedure by same physician	Use when the exact procedure is repeated by the same physician later the same day.
`77`	Repeat procedure by another physician	Use when the exact procedure is repeated by a different physician the same day.
`78`	Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period	Use for unplanned return to the procedure room for a complication related to the original endoscopy.
`79`	Unrelated procedure or service by the same physician during postoperative period	Use when a different, unrelated procedure is performed during the global period.
`26`	Professional component	Use when reporting only the physician’s interpretation and report (rare for endoscopy where global usually applies).

Taxonomy Code	Specialty	Notes
`207RC0000X`	Gastroenterology	Primary specialty performing diagnostic and therapeutic small-bowel endoscopy and biopsies.
`2080P0201X`	General Surgery	General surgeons who perform advanced endoscopy or intraoperative endoscopic procedures.
`363L00000X`	Colorectal Surgery	Colorectal surgeons who may perform enteroscopy in select cases.
`207LN0000X`	Transplant Hepatology	In select patients (e.g., post-transplant with suspected small bowel disease) involvement may occur.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K90.0`	Celiac disease	Indication for proximal small-bowel biopsy to confirm villous atrophy.
`K92.1`	Melena	Common presenting symptom prompting small bowel evaluation for occult bleeding.
`D50.9`	Iron deficiency anemia, unspecified	Unexplained iron-deficiency anemia frequently triggers endoscopic evaluation including small-bowel biopsy to identify bleeding or malabsorptive causes.
`K52.9`	Noninfective gastroenteritis and colitis, unspecified	When small-bowel inflammatory disease is suspected and biopsies are needed for diagnosis.
`R19.7`	Diarrhea, unspecified	Chronic diarrhea may lead to small-bowel evaluation and mucosal biopsies to assess for disorders like celiac disease or tropical sprue.
`C17.9`	Malignant neoplasm of small intestine, unspecified	Lesions suspected on imaging or endoscopy require biopsy for histologic diagnosis.
`K58.9`	Irritable bowel syndrome without diarrhea	Sometimes considered in differential diagnosis; biopsy may be performed to exclude organic disease.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`43235`	Upper GI endoscopy, flexible, transoral; with biopsy, single or multiple	Often performed when pathology is limited to the proximal upper GI tract; may be performed in conjunction or as an alternative depending on findings.
`44388`	Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)	Performed when lower GI evaluation is indicated for GI bleeding workup in the same episode of care.
`45380`	Colonoscopy, flexible; with biopsy, single or multiple	May be performed before or after small-bowel endoscopy when sampling of the colon is required as part of a bleeding or inflammatory workup.
`43239`	Upper GI endoscopy, flexible, transoral; with insertion of guidewire followed by other procedures	Related when additional endoscopic interventions in the upper GI tract are required during the same session.
`43202`	Esophagoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing	Performed when proximal esophageal pathology is suspected and simultaneous endoscopic evaluation is needed.

CPT 44360: Diagnostic Upper Small Bowel Endoscopy with Brushing

CPT-44363-ENDOSCOPIC-JEJUNAL-INTUBATION-FOREIGN-BODY-REMOVAL

CPT 44363: Endoscopic Examination and Foreign-Body Removal, Proximal Small Intestine

CPT-44364-SMALL-BOWEL-ENDOSCOPY-SNARE-POLYPECTOMY

CPT 44364: Small-Bowel Endoscopy with Snare Lesion Removal

CPT-44365-SMALL-INTESTINE-ENDOSCOPY-LESION-REMOVAL

CPT 44365: Small Intestine Endoscopy with Lesion Removal

CPT-44366-UPPER-SMALL-BOWEL-ENDOSCOPY-HEMOSTASIS

CPT 44366: Upper Small Bowel Endoscopy with Hemostasis

CPT-44369-ENDOSCOPIC-LASER-RADIOFREQUENCY-ABLATION-SMALL-BOWEL

CPT 44369: Endoscopic Laser/Radiofrequency Ablation of Upper Small Bowel Lesions

CPT-44370-UPPER-GI-ENDOSCOPY-DILATION-STENT-PLACEMENT

CPT 44370: Upper GI Endoscopy with Dilation and Stent Placement

CPT-44372-ENDOSCOPIC-JEJUNAL-FEEDING-TUBE-PLACEMENT

CPT 44372: Endoscopic Jejunostomy Tube Placement for Enteral Nutrition

CPT-44373-GASTROSTOMY-TO-JEJUNOSTOMY-CONVERSION-ENDOSCOPIC

CPT 44373: Endoscopic Conversion of Gastrostomy to Jejunostomy

CPT-44376-DIAGNOSTIC-UPPER-ENDOSCOPY-BRUSHING-LAVAGE

CPT 44376: Diagnostic Upper GI Endoscopy with Brushing or Lavage

Showing 1–10 of 13

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure	Use when a distinct E/M visit occurs on the same day as the endoscopic procedure and is documented separately.
`52`	Reduced services	Use when the endoscopic procedure is partially reduced or not completed for documented reasons.
`53`	Discontinued procedure	Use when the procedure is started but terminated due to patient condition or anatomic difficulty before completion.
`59`	Distinct procedural service	Use to indicate a separate, unrelated procedure or service performed on the same day.
`62`	Two surgeons	Use when two surgeons with different specialties are present and both perform distinct portions of the procedure.
`76`	Repeat procedure by same physician	Use when the exact procedure is repeated by the same physician later the same day.
`77`	Repeat procedure by another physician	Use when the exact procedure is repeated by a different physician the same day.
`78`	Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period	Use for unplanned return to the procedure room for a complication related to the original endoscopy.
`79`	Unrelated procedure or service by the same physician during postoperative period	Use when a different, unrelated procedure is performed during the global period.
`26`	Professional component	Use when reporting only the physician’s interpretation and report (rare for endoscopy where global usually applies).

Taxonomy Code	Specialty	Notes
`207RC0000X`	Gastroenterology	Primary specialty performing diagnostic and therapeutic small-bowel endoscopy and biopsies.
`2080P0201X`	General Surgery	General surgeons who perform advanced endoscopy or intraoperative endoscopic procedures.
`363L00000X`	Colorectal Surgery	Colorectal surgeons who may perform enteroscopy in select cases.
`207LN0000X`	Transplant Hepatology	In select patients (e.g., post-transplant with suspected small bowel disease) involvement may occur.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K90.0`	Celiac disease	Indication for proximal small-bowel biopsy to confirm villous atrophy.
`K92.1`	Melena	Common presenting symptom prompting small bowel evaluation for occult bleeding.
`D50.9`	Iron deficiency anemia, unspecified	Unexplained iron-deficiency anemia frequently triggers endoscopic evaluation including small-bowel biopsy to identify bleeding or malabsorptive causes.
`K52.9`	Noninfective gastroenteritis and colitis, unspecified	When small-bowel inflammatory disease is suspected and biopsies are needed for diagnosis.
`R19.7`	Diarrhea, unspecified	Chronic diarrhea may lead to small-bowel evaluation and mucosal biopsies to assess for disorders like celiac disease or tropical sprue.
`C17.9`	Malignant neoplasm of small intestine, unspecified	Lesions suspected on imaging or endoscopy require biopsy for histologic diagnosis.
`K58.9`	Irritable bowel syndrome without diarrhea	Sometimes considered in differential diagnosis; biopsy may be performed to exclude organic disease.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`43235`	Upper GI endoscopy, flexible, transoral; with biopsy, single or multiple	Often performed when pathology is limited to the proximal upper GI tract; may be performed in conjunction or as an alternative depending on findings.
`44388`	Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)	Performed when lower GI evaluation is indicated for GI bleeding workup in the same episode of care.
`45380`	Colonoscopy, flexible; with biopsy, single or multiple	May be performed before or after small-bowel endoscopy when sampling of the colon is required as part of a bleeding or inflammatory workup.
`43239`	Upper GI endoscopy, flexible, transoral; with insertion of guidewire followed by other procedures	Related when additional endoscopic interventions in the upper GI tract are required during the same session.
`43202`	Esophagoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing	Performed when proximal esophageal pathology is suspected and simultaneous endoscopic evaluation is needed.

CPT 44360: Diagnostic Upper Small Bowel Endoscopy with Brushing

CPT-44363-ENDOSCOPIC-JEJUNAL-INTUBATION-FOREIGN-BODY-REMOVAL

CPT 44363: Endoscopic Examination and Foreign-Body Removal, Proximal Small Intestine

CPT-44364-SMALL-BOWEL-ENDOSCOPY-SNARE-POLYPECTOMY

CPT 44364: Small-Bowel Endoscopy with Snare Lesion Removal

CPT-44365-SMALL-INTESTINE-ENDOSCOPY-LESION-REMOVAL

CPT 44365: Small Intestine Endoscopy with Lesion Removal

CPT-44366-UPPER-SMALL-BOWEL-ENDOSCOPY-HEMOSTASIS

CPT 44366: Upper Small Bowel Endoscopy with Hemostasis

CPT-44369-ENDOSCOPIC-LASER-RADIOFREQUENCY-ABLATION-SMALL-BOWEL

CPT 44369: Endoscopic Laser/Radiofrequency Ablation of Upper Small Bowel Lesions

CPT-44370-UPPER-GI-ENDOSCOPY-DILATION-STENT-PLACEMENT

CPT 44370: Upper GI Endoscopy with Dilation and Stent Placement

CPT-44372-ENDOSCOPIC-JEJUNAL-FEEDING-TUBE-PLACEMENT

CPT 44372: Endoscopic Jejunostomy Tube Placement for Enteral Nutrition

CPT-44373-GASTROSTOMY-TO-JEJUNOSTOMY-CONVERSION-ENDOSCOPIC

CPT 44373: Endoscopic Conversion of Gastrostomy to Jejunostomy

CPT-44376-DIAGNOSTIC-UPPER-ENDOSCOPY-BRUSHING-LAVAGE

CPT 44376: Diagnostic Upper GI Endoscopy with Brushing or Lavage

Showing 1–10 of 13

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

OpenPayer

CPT 44361: Endoscopic Examination of Proximal Small Intestine with Biopsy

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Billing Code Overview

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CPT 44361: Endoscopic Examination of Proximal Small Intestine with Biopsy

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Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References