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Pouchoscopy through rectum

Amy Posted Tue 01st of October, 2013 08:45:36 AM

In a prior post, you mention using 44385 for a total proctocolectomy patient, stating the scope is entered through the anus. My Contexo Media "Plain English" surgery book defines 44385/86 as entering through a stoma. Can you verify that 44385 would still be the correct code to use if there is no stoma, and the scope is entered through the rectum to examine the ileoanal pouch?

SuperCoder Answered Tue 01st of October, 2013 22:51:18 PM


Colonoscopy is a diagnostic procedure used to detect problems in the colon or the rectum. A pouchoscopy is performed on the small intestinal (abdominal or pelvic) pouch. So, a colonoscopy CPT® code cannot be used if pouchoscopy is the procedure your gastorenteroloist is performing. If pouchoscopy was the only procedure that your gastroenterologist performed, then you have to report the procedure using 44385 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). But, when your gastroenterologist also used dilators to overcome the strictures, if you only report the procedure with 44385, your reporting will only be half-correct.

CPT® does not cover many endoscopy procedures with separate codes. One such code that is not covered includes pouchoscopy along with dilation to overcome strictures using a balloon, bougie or a guidewire. Since, CPT® does not have a separate code for pouchoscopy with dilation you will have to report the pouchoscopy with 44385 and the dilation with 44799 (Unlisted procedure, intestine).

Since you are reporting an unlisted procedure code, you will have to submit a copy of the operative report along with documentation describing what additional procedures have been performed by your gastroenterologist. The documentation should also include the time that was taken by your gastroenterologist to perform the procedure.

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