Summary & Overview
CPT 44365: Small Intestine Endoscopy with Lesion Removal
CPT code 44365 represents an upper small intestinal endoscopy that advances past the second portion of the duodenum but stops short of the ileum, with removal of one or more lesions using hot biopsy forceps or bipolar cautery. This code captures combined diagnostic visualization and therapeutic polypectomy/lesion excision in the proximal small bowel. Nationally, the code matters for procedural classification, facility and professional billing, and appropriate coding of combined diagnostic and destructive techniques during enteroscopy procedures.
Key payers addressed in analyses typically include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for the procedure, guidance on typical sites of service, and where to expect claim activity for combined diagnostic and therapeutic enteroscopy. The publication also outlines common modifiers and coding relationships where available and highlights benchmarking and policy considerations relevant to payer coverage and claim adjudication. This summary serves clinicians, coding professionals, and reimbursement analysts seeking a clear description of CPT code 44365, its clinical application, and the payer landscape for national-level billing and policy alignment.
Billing Code Overview
CPT code 44365 describes an endoscopic examination of the small intestine that advances beyond the second portion of the duodenum but does not include the ileum. During the procedure the provider inspects the intestinal mucosa for abnormalities and removes one or more tumors, polyps, or other lesions using hot biopsy forceps or bipolar cautery.
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Service type: Diagnostic and therapeutic endoscopy with lesion removal
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Typical site of service: Endoscopy suite or hospital outpatient department
Clinical & Coding Specifications
Clinical Context
A 58-year-old male presents to the outpatient endoscopy suite with intermittent melena and iron-deficiency anemia. Prior noninvasive testing (fecal occult blood and labs) suggests occult GI blood loss. The gastroenterology team schedules an upper endoscopic evaluation extending past the second portion of the duodenum to inspect the jejunum up to but not including the ileum using a push enteroscope. During the procedure, the provider identifies one or more pedunculated and sessile polyps in the proximal jejunum and removes them using hot biopsy forceps and bipolar cautery to achieve complete excision and hemostasis. The clinical workflow includes pre-procedure consent and chart review, administration of moderate sedation in the endoscopy suite, endoscopic inspection and lesion removal with electrocautery, specimen collection for pathology, post-procedure recovery and discharge instructions, and documentation of procedural details, findings, and immediate complications if any. Typical site of service: hospital outpatient endoscopy unit or ambulatory surgical center. Service type: diagnostic and therapeutic endoscopy (push enteroscopy) with electrocautery polypectomy using hot biopsy forceps/bipolar cautery.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Professional component | Use when reporting the physician’s professional service distinct from facility technical component when required by payor policy. |