CPT code 44360 – Small intestinal endoscopy beyond the duodenum

Key Takeaways

CPT code 44360 covers diagnostic small intestinal endoscopy beyond the third portion of the duodenum, with no additional therapeutic interventions performed.

If any therapeutic service (biopsy, polypectomy, hemostasis) is performed during the same session, 44360 is replaced by the appropriate therapeutic code from the 443xx family, not billed alongside it.

Modifier -59 is typically required when CPT 44360 is billed on the same day as an EGD (CPT 43235) to bypass NCCI bundling edits.

Pabau integrates with Claim.MD to validate GI procedure codes, check ICD-10 pairings, and submit 837P claims electronically before denials occur.

CPT code 44360: Official descriptor and procedure overview

CPT code 44360 is a small intestinal endoscopy procedure code describing diagnostic examination of the small intestine beyond the third portion of the duodenum, not including the ileum when no ileal examination is performed. The American Medical Association (AMA) maintains this code within the digestive system subsection of the Surgery section, CPT code range 44360-44379.

The key phrase in the descriptor is “not including ileum.” Some versions of the descriptor add “when performed” for ileal examination, which creates confusion. The practical rule: 44360 covers the diagnostic pass through the proximal small bowel. If the physician documents examination of the ileum, that extends the reach but does not change the code as long as no therapeutic intervention was performed.

How push enteroscopy works: Clinical context for CPT code 44360

Push enteroscopy is performed by advancing a long endoscope (typically 220-250 cm) orally, past the stomach and duodenum, into the proximal jejunum. The anatomical landmark that separates CPT code 44360 from a standard EGD (CPT 43235) is the third portion of the duodenum. If the scope does not advance beyond that point, the procedure is an EGD, not an enteroscopy.

Documentation must confirm the scope reached the proximal jejunum or beyond. Without that confirmation, payers default the claim to CPT 43235, with a significantly lower reimbursement rate.

• Equipment used: Push enteroscope (220-250 cm working length) or pediatric colonoscope used off-label for push technique
• Anatomical entry point: Oral, through esophagus and stomach into small bowel
• Target depth: Beyond the third portion of the duodenum, typically into proximal jejunum
• Differentiator from EGD: EGD (CPT 43235) ends at the second or third portion of the duodenum; enteroscopy goes further
• Diagnostic purpose: Visualization of proximal small bowel mucosa for bleeding sources, inflammatory disease, or mass lesions
• 44360 vs therapeutic codes: If any intervention is performed, the base code is replaced by the therapeutic code from the 443xx family

What CPT 44360 includes and excludes

CPT code 44360 is a base diagnostic code. Understanding exactly what it covers prevents both underbilling (missing a therapeutic code) and overbilling (bundling therapeutic services with the diagnostic base code).

The substitution rule applies: When a therapeutic intervention is performed, CPT code 44360 is replaced by the most complex service performed. It is not billed alongside the therapeutic code. Billing both 44360 and 44361 for the same session is a bundling error that NCCI edits will catch.

CPT 44360 vs 44361 and the full 443xx code family

The 443xx small intestinal endoscopy family shares a common foundation: Each code describes enteroscopy beyond the third portion of the duodenum, differentiated only by what therapeutic service was added. CPT 44360 vs 44361 is the most frequently confused pair, because a single cold forceps biopsy transforms the diagnostic code into the therapeutic one.

The substitution principle applies to the entire family. Each therapeutic code already includes the diagnostic examination; there is no add-on relationship between 44360 and its siblings.

ICD-10 diagnosis codes supporting medical necessity for CPT code 44360

Medical necessity is the most common audit trigger for CPT code 44360. Payers require the linked ICD-10-CM diagnosis to explain why small bowel examination was clinically necessary. An unlisted diagnosis or one that does not support proximal small bowel evaluation is a top denial cause.

Covered diagnoses differ by LCD jurisdiction. Verify the applicable Local Coverage Determination for the performing provider’s MAC before assuming any diagnosis on this table is universally accepted. Payers with specific LCDs for small bowel endoscopy may require documentation that standard EGD and colonoscopy were non-diagnostic before authorizing CPT code 44360.

Modifiers for CPT code 44360

Modifier selection for CPT code 44360 is most consequential when the procedure is performed on the same day as an EGD or colonoscopy. The wrong modifier choice results in an NCCI bundling denial; missing the modifier entirely produces the same outcome.

Verify current NCCI bundling edits quarterly. Bundling edits for GI endoscopy codes change, and a modifier combination that was correct six months ago may not be accepted by the same payer today.

Medicare reimbursement rates and RVU breakdown for CPT code 44360

Medicare reimbursement for CPT code 44360 varies by place of service and geographic locality. The figures below reflect the 2025 Medicare Physician Fee Schedule national averages. Rates change with each annual MPFS update. Always verify current rates using the CMS Physician Fee Schedule Look-Up Tool before using any figure for billing projections.

Gastroenterology practices billing CPT code 44360 from an ASC setting (POS 24) will receive the facility rate, with the ASC facility fee billed separately by the facility. The physician component does not include the facility’s overhead in that setting. Practices performing enteroscopy in-office at POS 11 receive the higher non-facility rate, which incorporates practice expense.

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Prior authorization and payer requirements

Prior authorization requirements for CPT code 44360 vary significantly by payer and plan type. Medicare does not require prior authorization for most outpatient endoscopic procedures, but commercial payers often do, particularly for outpatient hospital or ASC settings. Understanding medical billing workflows that front-load authorization checks saves the practice the cost of an avoidable denial on a procedure that has already been performed.

• Medicare inpatient: Prior auth generally not required for 44360 as an inpatient procedure
• Medicare outpatient (ASC or hospital): No universal prior auth requirement, but LCD-specific documentation may be required upfront for certain diagnoses
• Commercial payers: Many require prior auth for enteroscopy; contact the specific payer’s provider line before scheduling
• Managed Medicaid: Prior auth requirements vary by state and managed care organization; treat each plan separately
• Documentation for auth request: Include indication for the procedure, results of previous EGD and colonoscopy (confirming they were non-diagnostic), and the clinical rationale for small bowel examination
• LCD policies: CMS contractors publish LCDs for GI endoscopy; check the applicable MAC’s LCD for your practice’s jurisdiction

Documentation requirements for CPT code 44360 claims

Inadequate documentation is the second most common reason a CPT code 44360 claim fails audit. The operative or procedure note must do two things: Confirm the scope reached the correct anatomical depth, and confirm that no therapeutic intervention was performed. Missing either element gives a payer grounds to deny or downcode the claim.

• Anatomical depth confirmation: The note must state the scope advanced beyond the third portion of the duodenum. Phrases such as “examined to the proximal jejunum” or “scope advanced approximately X cm beyond the ligament of Treitz” are acceptable; “upper endoscopy performed” is not.
• Indication/medical necessity: State the clinical indication that justified the procedure. Cross-reference the ICD-10-CM diagnosis code used on the claim.
• Findings documented: Describe mucosal findings or confirm normal appearance. Absence of documented findings suggests an incomplete examination.
• No specimens taken: If the diagnostic base code 44360 is billed, the note must confirm no biopsies, polypectomies, or other interventions were performed.
• Procedure time: Document start and end time of scope insertion and withdrawal, particularly if anesthesia is billed separately.
• Physician attestation: Signed, dated attestation that the note is complete and accurate. Required for all Medicare claims.

Pabau’s claims management software integrates with Claim.MD to validate procedure code and diagnosis code combinations before the 837P file is transmitted. Practices using this workflow catch documentation mismatches before they become denials. For electronic claim submission and real-time eligibility checks, electronic claim submission through Claim.MD routes GI procedure claims to more than 4,000 US payers with built-in CPT and ICD-10 catalogues to flag errors pre-transmission.

Common claim denial reasons for CPT 44360 and how to fix them

Most denials on CPT code 44360 are preventable. The table below covers the six most frequent denial patterns, their root causes, and the corrective action for each. Strong denial management workflows catch the majority of these before the claim transmits.

When appealing a denial, submitting a clean claim on the corrected submission is critical. A second denial on a corrected claim often triggers a secondary review that takes longer to resolve than the original appeal.

Global period and post-procedure billing for CPT code 44360

CPT code 44360 carries a -day global period under the CMS Medicare Physician Fee Schedule. A zero-day global means the procedure fee includes only the intraoperative services and immediate post-procedure care. It does not include any same-day E&M service, and it does not create a post-operative bundle period extending into subsequent days.

Three scenarios arise most often in post-procedure billing for 44360:

• Same-day E&M service: If a separately identifiable evaluation and management service was provided on the day of 44360, bill the E&M with modifier -25. The E&M must be documented as clinically distinct from routine pre/post-procedure assessment. Routine counseling about findings at scope withdrawal does not qualify.
• Follow-up visit the same day: A routine post-procedure visit on the same day as 44360 is included in the procedure fee and cannot be billed separately without modifier -25 and documentation of a separately identifiable service.
• Follow-up visit on a subsequent day: Because the global period is zero days, an E&M visit on the day after 44360 is fully billable without any modifier. The global window has already closed.

Confirm the -day global period designation against the current CMS MPFS database. Global period designations can change with annual fee schedule updates, and relying on prior-year data for modifier decisions is an audit risk. The AAPC Codify CPT lookup provides global period data alongside the official descriptor for quick verification.

Conclusion

Getting CPT code 44360 right comes down to three things: Confirming the scope reached the correct anatomical depth, documenting that no therapeutic service was performed, and linking a diagnosis that the applicable LCD actually accepts. Miss any one of these and the claim goes back.

Pabau’s integrated claims management workflow validates GI procedure codes against ICD-10-CM pairings before an 837P file is transmitted, flagging mismatches that would otherwise become denials.

To see how Pabau handles gastroenterology billing workflows end to end, book a demo.

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