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CPT 44385: Endoscopic Evaluation of Ileal Pouch with Specimen Collection

CPT code 44385 covers endoscopic inspection of a previously constructed small intestinal (ileal) pouch and the ileal pouch–anal anastomosis with collection of specimens by brush or irrigation/washings for laboratory analysis. This procedure is used to evaluate pouch mucosa for inflammation, dysplasia, infection, or other abnormal tissue after restorative proctocolectomy.

Nationally, CPT code 44385 is relevant to colorectal surgeons, gastroenterologists, ambulatory surgery centers, and payers managing postoperative surveillance and diagnostic pathways for patients with ileal pouches. Key payers commonly involved in coverage and reimbursement for this service include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will find concise clinical and billing context for CPT code 44385, including the clinical setting and specimen collection methods, typical sites of service, and the payer landscape. The publication summarizes operational considerations, common modifiers, and where to look for supporting documentation and coding guidance. Data not available in the input is noted where applicable.

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Billing Code Overview

CPT code 44385 describes an endoscopic examination of a previously created small intestinal pouch and the anastomosis between the ileal pouch and the anus. The provider inserts an endoscope through the anus to inspect the pouch mucosa and the surgical connection. When abnormal mucosa or tissue is identified, the clinician may collect diagnostic specimens by brushing the area through the scope or by irrigating with warm saline and aspirating washings for laboratory analysis.

Service Type: Endoscopic evaluation with specimen collection from ileal pouch/anastomosis

Typical Site of Service: Endoscopy suite or ambulatory surgical center

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CPT 44385: Endoscopic Evaluation of Ileal Pouch with Specimen Collection

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Billing Code Overview

Service Type: Endoscopic evaluation with specimen collection from ileal pouch/anastomosis

Typical Site of Service: Endoscopy suite or ambulatory surgical center

Clinical & Coding Specifications

Clinical Context

A 48-year-old patient with a history of ulcerative colitis underwent total proctocolectomy with ileal pouch-anal anastomosis (IPAA) two years prior. The patient presents with intermittent pelvic pain, increased stool frequency, and occasional bleeding. The gastroenterologist schedules an office-based pouchoscopy using a flexible endoscope passed through the anus to visualize the ileal pouch and the anastomosis. During the procedure the provider inspects the mucosa for inflammation, ulceration, strictures, or dysplastic changes. If abnormal areas are identified, the clinician collects cytologic brushings or performs pouch irrigation with warm saline and aspirates washings for laboratory analysis. The specimens are labeled and sent to the pathology and microbiology laboratories for cytology, histology, and/or culture as indicated. Typical documentation includes indication, informed consent, anesthesia or sedation used, procedural findings, specimens obtained, and disposition. The typical site of service is an ambulatory endoscopy suite or hospital outpatient endoscopy unit. The service type is diagnostic endoscopy with specimen collection (brushings/washings) of an existing ileal pouch and pouch-anal anastomosis, represented by 44385.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the physician interpretation or procedural component separate from the facility/technical portion.
`51`	Multiple procedures	Use when `44385` is performed in the same session with other distinct endoscopic procedures billed by the same provider.
`52`	Reduced services	Use when the procedure is partially reduced or not completed for documented clinical reasons.
`53`	Discontinued procedure	Use when the procedure is started but terminated due to emergent circumstances prior to completion.
`59`	Distinct procedural service	Use to indicate a separate, distinct procedure when another service might be bundled; supports unbundling when clinically appropriate.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons during a complex operative portion related to pouch revision (rare for diagnostic pouchoscopy).
`76`	Repeat procedure by same physician	Use when the same provider repeats the pouchoscopy within the global period due to persistent/recurrent indication.
`77`	Repeat procedure by another physician	Use when a second physician repeats the procedure after a prior attempt by a different physician.
`78`	Unplanned return to the operating/procedure room by the same physician following initial procedure for a related complication during the same hospitalization.	Use if a return to procedure room is required for management of an acute complication arising from the pouchoscopy.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use when a separate unrelated procedure is performed during the postoperative period.
`26`	Professional component	(duplicate entry avoided in billing; included above as primary relevant modifier.)
`TC`	Technical component	Use when billing only the facility or technical portion of the service, such as equipment, supplies, and non-physician staff.
`52`	Reduced services	(listed above; included for emphasis when sedation or extent of procedure is limited.)

Taxonomy Code	Specialty	Notes
`207RH0000X`	Colon & Rectal Surgery	Surgeons who manage pouch complications and perform operative interventions.
`208000000X`	Gastroenterology	Endoscopists who perform diagnostic pouchoscopy and specimen collection.
`207L00000X`	General Surgery	Surgeons with experience in abdominal/pelvic surgical follow-up and pouch evaluation.
`2084P0800X`	Pediatric Gastroenterology	Performs pouchoscopy in adolescent patients with prior IPAA.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K51.90`	Ulcerative colitis, unspecified, without complications	Common indication for prior proctocolectomy with IPAA and for surveillance of pouch inflammation or pouchitis.
`K63.1`	Ileostomy (status)	Reflects prior surgical diversion; relevant to patients with altered anatomy requiring pouch evaluation.
`K52.89`	Other specified noninfective gastroenteritis and colitis	Differential diagnosis for pouch inflammation and symptoms prompting pouchoscopy.
`K91.89`	Other postprocedural complications and disorders of digestive system	Used when investigating postoperative complications of IPAA such as strictures, leaks, or chronic pain.
`R19.4`	Change in bowel habit	Symptom code often accompanying clinical indications for pouchoscopy, such as increased stool frequency.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`45378`	Colonoscopy, flexible, proximal to splenic flexure; diagnostic, including collection of specimens by brushing or washing, when performed (separate procedure).	Performed when evaluation of the remaining colon is indicated in addition to pouchoscopy; may occur in the same session when anatomy permits.
`44388`	Endoscopic examination, ileostomy or ileal pouch, with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.	Therapeutic complement when lesions identified during `44385` require endoscopic resection rather than only brushings/washings.
`45380`	Colonoscopy, flexible; with biopsy, single or multiple.	Frequently performed alongside `44385` if mucosal biopsies are needed in addition to brushings/washings.
`91110`	Gastrointestinal tract imaging for tube placement and/or radiologic assessment (contrast instillation) (example code).	May be used in the workflow if contrast studies of the pouch are needed for stricture evaluation prior to or after endoscopy.
`99152`	Moderate sedation services provided by the same physician performing the procedure (initial 15 minutes) — intra-service time-based sedation code.	Billed when the endoscopist provides moderate sedation for the pouchoscopy; may be applicable depending on payer rules.

CPT 44380: Stomal Ileoscopy, Endoscopic Examination of Ileum

CPT-44381-ILEOSCOPY-THROUGH-STOMA-WITH-BALLOON-DILATION

CPT 44381: Ileoscopy Through Stoma with Endoscopic Balloon Dilation

CPT-44382-ILEOSCOPY-THROUGH-STOMA-BIOPSY

CPT 44382: Ileoscopy Through Stoma with Biopsy

CPT-44384-ILEOSCOPY-WITH-STENT-PLACEMENT-THROUGH-STOMA

CPT 44384: Ileoscopy Through Stoma with Endoscopic Stent Placement

CPT-44386-ENDOSCOPIC-POUCHOSCOPY-WITH-BIOPSY

CPT 44386: Endoscopic Examination of Ileal Pouch With Biopsy

CPT-44388-COLONOSCOPY-VIA-COLOSTOMY-STOMA-SURVEILLANCE

CPT 44388: Colonoscopy via Colostomy Stoma for Surveillance

CPT-44389-STOMAL-COLONOSCOPY-WITH-BIOPSY

CPT 44389: Endoscopic Stomal Colonoscopy with Biopsy

CPT-44390-COLONOSCOPY-THROUGH-COLOSTOMY-STOMA-FOREIGN-BODY-REMOVAL

CPT 44390: Colonoscopy Through Colostomy Stoma with Foreign Body Removal

CPT-44391-COLONOSCOPY-VIA-COLOSTOMY-STOMA-THERAPEUTIC-EVALUATION

CPT 44391: Colonoscopy via Colostomy Stoma with Endoscopic Repair

CPT-44392-COLONOSCOPY-THROUGH-COLOSTOMY-LESION-EXCISION

CPT 44392: Colonoscopy via Colostomy with Excision of Lesion(s)

Showing 1–10 of 19

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.

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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
`26`	Professional component	Use when billing only the physician interpretation or procedural component separate from the facility/technical portion.
`51`	Multiple procedures	Use when `44385` is performed in the same session with other distinct endoscopic procedures billed by the same provider.
`52`	Reduced services	Use when the procedure is partially reduced or not completed for documented clinical reasons.
`53`	Discontinued procedure	Use when the procedure is started but terminated due to emergent circumstances prior to completion.
`59`	Distinct procedural service	Use to indicate a separate, distinct procedure when another service might be bundled; supports unbundling when clinically appropriate.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons during a complex operative portion related to pouch revision (rare for diagnostic pouchoscopy).
`76`	Repeat procedure by same physician	Use when the same provider repeats the pouchoscopy within the global period due to persistent/recurrent indication.
`77`	Repeat procedure by another physician	Use when a second physician repeats the procedure after a prior attempt by a different physician.
`78`	Unplanned return to the operating/procedure room by the same physician following initial procedure for a related complication during the same hospitalization.	Use if a return to procedure room is required for management of an acute complication arising from the pouchoscopy.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use when a separate unrelated procedure is performed during the postoperative period.
`26`	Professional component	(duplicate entry avoided in billing; included above as primary relevant modifier.)
`TC`	Technical component	Use when billing only the facility or technical portion of the service, such as equipment, supplies, and non-physician staff.
`52`	Reduced services	(listed above; included for emphasis when sedation or extent of procedure is limited.)

Taxonomy Code	Specialty	Notes
`207RH0000X`	Colon & Rectal Surgery	Surgeons who manage pouch complications and perform operative interventions.
`208000000X`	Gastroenterology	Endoscopists who perform diagnostic pouchoscopy and specimen collection.
`207L00000X`	General Surgery	Surgeons with experience in abdominal/pelvic surgical follow-up and pouch evaluation.
`2084P0800X`	Pediatric Gastroenterology	Performs pouchoscopy in adolescent patients with prior IPAA.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K51.90`	Ulcerative colitis, unspecified, without complications	Common indication for prior proctocolectomy with IPAA and for surveillance of pouch inflammation or pouchitis.
`K63.1`	Ileostomy (status)	Reflects prior surgical diversion; relevant to patients with altered anatomy requiring pouch evaluation.
`K52.89`	Other specified noninfective gastroenteritis and colitis	Differential diagnosis for pouch inflammation and symptoms prompting pouchoscopy.
`K91.89`	Other postprocedural complications and disorders of digestive system	Used when investigating postoperative complications of IPAA such as strictures, leaks, or chronic pain.
`R19.4`	Change in bowel habit	Symptom code often accompanying clinical indications for pouchoscopy, such as increased stool frequency.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`45378`	Colonoscopy, flexible, proximal to splenic flexure; diagnostic, including collection of specimens by brushing or washing, when performed (separate procedure).	Performed when evaluation of the remaining colon is indicated in addition to pouchoscopy; may occur in the same session when anatomy permits.
`44388`	Endoscopic examination, ileostomy or ileal pouch, with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.	Therapeutic complement when lesions identified during `44385` require endoscopic resection rather than only brushings/washings.
`45380`	Colonoscopy, flexible; with biopsy, single or multiple.	Frequently performed alongside `44385` if mucosal biopsies are needed in addition to brushings/washings.
`91110`	Gastrointestinal tract imaging for tube placement and/or radiologic assessment (contrast instillation) (example code).	May be used in the workflow if contrast studies of the pouch are needed for stricture evaluation prior to or after endoscopy.
`99152`	Moderate sedation services provided by the same physician performing the procedure (initial 15 minutes) — intra-service time-based sedation code.	Billed when the endoscopist provides moderate sedation for the pouchoscopy; may be applicable depending on payer rules.

CPT 44380: Stomal Ileoscopy, Endoscopic Examination of Ileum

CPT-44381-ILEOSCOPY-THROUGH-STOMA-WITH-BALLOON-DILATION

CPT 44381: Ileoscopy Through Stoma with Endoscopic Balloon Dilation

CPT-44382-ILEOSCOPY-THROUGH-STOMA-BIOPSY

CPT 44382: Ileoscopy Through Stoma with Biopsy

CPT-44384-ILEOSCOPY-WITH-STENT-PLACEMENT-THROUGH-STOMA

CPT 44384: Ileoscopy Through Stoma with Endoscopic Stent Placement

CPT-44386-ENDOSCOPIC-POUCHOSCOPY-WITH-BIOPSY

CPT 44386: Endoscopic Examination of Ileal Pouch With Biopsy

CPT-44388-COLONOSCOPY-VIA-COLOSTOMY-STOMA-SURVEILLANCE

CPT 44388: Colonoscopy via Colostomy Stoma for Surveillance

CPT-44389-STOMAL-COLONOSCOPY-WITH-BIOPSY

CPT 44389: Endoscopic Stomal Colonoscopy with Biopsy

CPT-44390-COLONOSCOPY-THROUGH-COLOSTOMY-STOMA-FOREIGN-BODY-REMOVAL

CPT 44390: Colonoscopy Through Colostomy Stoma with Foreign Body Removal

CPT-44391-COLONOSCOPY-VIA-COLOSTOMY-STOMA-THERAPEUTIC-EVALUATION

CPT 44391: Colonoscopy via Colostomy Stoma with Endoscopic Repair

CPT-44392-COLONOSCOPY-THROUGH-COLOSTOMY-LESION-EXCISION

CPT 44392: Colonoscopy via Colostomy with Excision of Lesion(s)

Showing 1–10 of 19

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.

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CPT 44385: Endoscopic Evaluation of Ileal Pouch with Specimen Collection

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Billing Code Overview

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CPT 44385: Endoscopic Evaluation of Ileal Pouch with Specimen Collection

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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