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advise on coding 44386 or 45331

louise Posted Fri 17th of May, 2019 11:16:05 AM
CF-H180AL was introduced through the ileoanal anastomosis via the anus and advanced to the ileoanal pouch and                          into the neo-terminal ileum.                          *   status-post total colectomy with an ileal pouch-anal anastomosis.                          evidence of a prior ileal pouch-anal anastomosis in                          the J-pouch. . The anastomosis was traversed. Biopsies were                          taken with a cold forceps for histology.                          The ileoanal pouch and neo-terminal ileum contained a few                          localized non-bleeding aphthae. Biopsies were taken with a cold forceps.
SuperCoder Answered Mon 20th of May, 2019 08:54:44 AM

Thank you for your Question.


CPT code 44386 (Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple) would be appropriate as per the above provided documentation. As CPT code 44386 includes the procedure in which provider passes an endoscope through the anus and examines a previously created small intestinal pouch and the anastomosis, the connection between the ileal pouch and the anus. If he sees any areas of abnormal mucosa or tissue, he biopsies one or more suspicious areas and sends the samples to the laboratory for diagnostic examination.


Hope this Helps!

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