Your gastroenterologist might use different techniques for enteroscopy. The three different techniques used by gastroenterologists for enteroscopy include:
Single balloon enteroscopy
Double balloon enteroscopy
Spiral enteroscopy
Note that there are no separate CPT® codes for the different techniques of enteroscopy your gastroenterologist might use. Instead, while choosing the right code to report you will have to concentrate on the following guidelines:
The approach used -- The most common approach is through the mouth (antegrade approach) although sometimes your gastroenterologist might view the distal portions of the ileum using a retrograde approach through the rectum.
The extent to which the small intestine was visualized
The purpose of the procedure (such as visualization, biopsy, removal of a lesion using a snare, control of bleeding, etc)
Example: If your gastroenterologist used a single balloon enteroscopy procedure to visualize the small intestine through an antegrade approach, then you can use 44360 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) if your gastroenterologist did not visualize the ileum and 44376 (…including ileum…) if the entire small intestine including the ileum was visualized.
Suppose during the procedure your gastroenterologist took a biopsy specimen, then you have to report the procedure using 44361 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple) or 44377 (…including ileum…) depending on the extent to which the scope was advanced.
Instead, if your gastroenterologist used a retrograde approach for the enteroscopy procedure, you will have to use the unlisted procedure code 44799 (Unlisted procedure, intestine) as there is no separate CPT® code to report the procedure done using a retrograde approach.