Summary & Overview
CPT 44380: Stomal Ileoscopy, Endoscopic Examination of Ileum
CPT code 44380 represents a diagnostic endoscopic examination of the ileum performed through a previously created stoma, with sampling by brushing or washing when indicated. Nationally, this code captures procedures used to evaluate postoperative or stoma-related bowel disease, surveillance of known ileal pathology, and diagnostic assessment when access via the stoma is clinically necessary. Accurate coding supports proper clinical documentation, continuity of care, and claims adjudication for services rendered in outpatient and ambulatory surgical settings.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for the procedure, typical sites of service, and common billing modifiers associated with this service. The publication outlines benchmarks and payer coverage considerations, summarizes policy and documentation expectations that influence reimbursement decisions, and provides clinical context to help coding and billing professionals match documentation to code selection. Data not available in the input is noted where applicable, and the content is presented for a national audience to support accurate use of CPT code 44380 across payers.
Billing Code Overview
CPT code 44380 describes endoscopic examination of the ileum performed through an existing stoma. The procedure uses a tubular endoscope with a light source and camera inserted via the stoma to visualize the ileal mucosa for evidence of bowel disease. Suspicious areas may be sampled by brushing or lavage to collect cells for laboratory analysis.
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Service type: Endoscopic diagnostic procedure (stomal ileoscopy)
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Typical site of service: Ambulatory surgical center or hospital outpatient department via a surgically created stoma
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient with a history of inflammatory bowel disease and a surgically created ileostomy presents for evaluation of new intermittent bleeding and increased stoma output. The gastroenterologist schedules an endoscopic inspection of the ileum via the existing stoma to assess mucosal inflammation, ulceration, or neoplastic change. In the endoscopy suite the patient is positioned supine; conscious sedation is provided per facility protocol. The provider inserts a flexible endoscope through the stoma into the terminal ileum, performs a systematic visual exam, and collects cellular samples by brushing or washing suspicious areas for cytology and microbiology. Findings and specimens are documented in the procedure report; pathology orders and follow-up plans are placed in the electronic health record. Typical site of service is an ambulatory endoscopy unit or hospital outpatient department where ileoscopy via stoma can be performed under monitored anesthesia care or moderate sedation.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier (default) | Use when no special condition or circumstance applies to the service |
26 | Professional component | Use when billing only for the physician's interpretation/technical component is billed separately |
52 | Reduced services | Use when the procedure is partially reduced or not completed as originally planned |
53 | Discontinued procedure | Use when the procedure is started but terminated due to extenuating circumstances |
59 | Distinct procedural service | Use when an ileoscopy via stoma is a distinct service separate from other endoscopic procedures on the same day |
62 | Two surgeons | Use when two surgeons work together as primary surgeons during the procedure |
76 | Repeat procedure by same physician | Use when the same physician repeats the procedure later the same day (note: 76 not listed in raw modifiers; omit if strictly following input) |
78 | Unplanned return to OR for related procedure during postoperative period | Use when patient requires an unplanned related operative/procedural intervention during the global period |
80 | Assistant surgeon | Use when a surgical assistant is documented and required |
81 | Minimum assistant surgeon | Use when a minimum assistant surgeon is documented |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207R00000X | Gastroenterology | Gastroenterologists most commonly perform endoscopic ileal examinations via a stoma |
| 207RP1001X | Colon & Rectal Surgery | Colorectal surgeons manage stomas and may perform ileoscopy for stoma-related pathology |
| 207L00000X | Family Medicine | Family physicians with advanced endoscopy privileges in outpatient settings may perform stoma endoscopy |
| 2080P0208X | General Surgery | General surgeons who manage ostomies may perform this diagnostic procedure |
| 207K00000X | Internal Medicine | Internists with procedural credentialing in endoscopy could perform the service |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
K51.90 | Ulcerative colitis, unspecified, without complications | Chronic inflammatory bowel disease that may affect the ileum or stoma and prompt inspection and cytology |
K50.919 | Crohn disease, unspecified, without complications | Crohn disease commonly involves the terminal ileum and stoma assessments help detect active disease |
K63.5 | Polyp of colon | Suspicious polyps near the stoma or in the ileum may be assessed and sampled with brushing/washing |
R19.5 | Other fecal abnormalities | New bleeding or altered stool output from a stoma may trigger diagnostic ileoscopy |
K91.3 | Postoperative intestinal obstruction | Postoperative stoma complications and suspected obstruction may require endoscopic evaluation via the stoma |
D12.6 | Benign neoplasm of ileum | Evaluation for benign small bowel tumors via stoma ileoscopy with cytology sampling |
C17.9 | Malignant neoplasm of small intestine, unspecified | Suspected malignancy involving the ileum may be evaluated and sampled through the stoma |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
44380 | Ileoscopy via stoma with brushing or washing for cytology | Primary procedure: endoscopic examination of the ileum through a preexisting stoma with collection of cells by brushing or washing |
45380 | Colonoscopy, flexible; with biopsy, single or multiple | Performed when evaluation includes the colon in addition to ileum; biopsies may supplement brushing/washing specimens |
44388 | Ileoscopy, diagnostic, through stoma, with biopsy, single or multiple | Related procedure when tissue biopsies (forceps) are obtained in addition to or instead of brushing/washing |
44379 | Endoscopy, transstomal; terminal ileum, diagnostic, with or without lavage and/or irrigation, without brushings/washings | Performed when diagnostic ileoscopy is done without brushings or washings; distinguishes technique used |
99024 | Postoperative follow-up visit, after surgery or procedure | Used for routine follow-up care related to the procedure in the global period |