Summary & Overview
CPT 44386: Endoscopic Examination of Ileal Pouch With Biopsy
CPT code 44386 represents an endoscopic examination of a previously created small intestinal (ileal) pouch and its anastomosis to the anus, with biopsy of suspicious mucosal areas when encountered. This procedure is clinically important for monitoring pouch health after restorative proctocolectomy with ileal pouch-anal anastomosis, evaluating complications such as inflammation, dysplasia, or anastomotic abnormalities, and guiding pathology-directed management. Nationally, accurate coding for pouchoscopy with biopsy affects clinical tracking, quality measures, and administrative reimbursement for outpatient endoscopy services.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for 44386, common sites of service, and the procedure components. The publication also summarizes expected billing practices, typical payer coverage considerations, and how 44386 is used in medical documentation. Where specific payer policy detail is not available in the source input, the text notes that data are not provided. This brief prepares clinicians, billing professionals, and policy analysts to identify 44386 in claims, understand its clinical purpose, and locate further payer-specific guidance as needed.
Billing Code Overview
CPT code 44386 describes a diagnostic endoscopic examination of a previously constructed small intestinal pouch and the anastomosis between the ileal pouch and the anus, performed via passage of an endoscope through the anus. The procedure includes visual inspection of the pouch mucosa and biopsy sampling of one or more suspicious areas for pathological analysis.
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Service type: Endoscopic diagnostic pouchoscopy with biopsy
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Typical site of service: Ambulatory endoscopy suite or hospital outpatient endoscopy unit
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult with a history of restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) presenting for surveillance or evaluation of pouch symptoms such as increased stool frequency, rectal pain, bleeding, or suspected pouchitis. The patient arrives to an outpatient endoscopy suite or ambulatory surgical center after bowel prep and informed consent. The colorectal surgeon or gastroenterologist performs a flexible pouchoscopy by passing a colonoscope/endoscope through the anus to inspect the ileal pouch mucosa and the ileal pouch–anal anastomosis. The provider documents mucosal appearance, inflammation, strictures, or suspicious lesions. If abnormal areas are identified, targeted biopsies are obtained and specimens are submitted to pathology with appropriate labeling. Procedure documentation includes indication, findings, specimens collected, anesthesia/sedation used, and post-procedure recovery instructions. Typical sites of service are the ambulatory endoscopy suite, outpatient hospital endoscopy unit, or office-based surgical suite.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when reporting only the physician’s professional interpretation separate from technical services when applicable (rare for endoscopy billing splits). |
52 |