CPT 44361 Reimbursement & Policy Benchmarks

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.

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

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.

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.

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Summary & Overview

CPT 44361: Endoscopic Examination of Proximal Small Intestine with Biopsy