Code1 Code Description
44360 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $663.06
44361 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple $663.06
44376 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
44377 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple
44365 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
Enteroscopy
A new definition and instructions for reporting antegrade transoral small intestine endoscopy (i.e., enteroscopy) have been added to the section guidelines. Enteroscopy is defined by the most distal segment of small intestine that is examined; coding does not reflect the technology used to perform the examination.
Codes in the 44360 family for enteroscopy, not including ileum (44360–44373), are endoscopic procedures to visualize the esophagus through the jejunum using an antegrade approach. Codes in the 44376 family for enteroscopy, including ileum (44376–44379), are endoscopic procedures to visualize the esophagus through the ileum using an antegrade approach.
If an endoscope cannot be advanced at least 50 cm beyond the pylorus, see the appropriate code in the EGD family (43233, 43235–43259, 43266, 43270). If an endoscope can be passed at least 50 cm beyond pylorus, but only into jejunum, see the appropriate code in the enteroscopy, not including ileum family (44360–44373).
To report retrograde examination of small intestine via anus or colon stoma, use 44799, Unlisted procedure, small intestine.
There were no changes to the language of the individual CPT codes.
If an endoscopy or enteroscopy is performed as a common standard of practice when performing another service, the endoscopy or enteroscopy is not separately reportable. For example, if a small intestinal endoscopy or enteroscopy is performed during the creation or revision of an enterostomy, the small intestinal endoscopy or enteroscopy is not separately reportable.
Upper Endoscopy
• Esophagoscopy Only view esophagus to LES
• Esophagogastroduodenoscopy
* Standard procedure
* Esophagus – stomach – duodenal bulb – 2 nd part
duodenum
• Push enteroscopy
* Using pediatric colonoscopy
* Advance to Jejunum
Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list. We recommend consulting your relevant manuals for appropriate coding options.
It is important to remember that surgical endoscopy always includes a diagnostic endoscopy (CPT® Code 43200). Therefore, when a diagnostic endoscopy is performed during the same session as a surgical endoscopy, the diagnostic endoscopy code is not separately reported. (CPT Assistant, October 2001)
BACKGROUND
Enteroscopy refers to endoscopic examination of the small intestine. Although limited small-bowel evaluation is undertaken during EGD and is possible during colonoscopy, enteroscopy typically refers to more extensive endoscopic examination of the small intestine, extending into the jejunum and/or ileum. Diagnostic evaluation of the small bowel can be performed by noninvasive imaging (CT or magnetic resonance enterography) or by wireless capsule endoscopy (WCE). Whereas these modalities currently lack therapeutic ability, they often precede and serve to guide and direct therapy via enteroscopy. WCE was discussed in a previous ASGE Technology Committee document.1 This document will focus on endoscopes, devices, and techniques used for enteroscopy and represents an update of a previous ASGE Technology Status Evaluation Report titled “Enteroscopes.”
TECHNOLOGY UNDER REVIEW
Push enteroscopy
This procedure may be performed with a specifically designed enteroscope or by using a colonoscope with or without an overtube. Typically evaluation is limited to
the proximal jejunum.
Device-assisted enteroscopy
Deeper evaluation of the small bowel can be accomplished with enteroscopes coupled with a specialized overtube apparatus. The procedure can be performed via an
antegrade approach (via the mouth) or via a retrograde approach (via the anus). In the United States, current options for device-assisted enteroscopes include doubleballoon enteroscopy (DBE), single-balloon enteroscopy (SBE), and spiral enteroscopy. A newer through-the-scope balloon-assisted device that allows “on-demand” enteroscopy is also available.
Intraoperative enteroscopy
This is a technique in which an endoscope is inserted orally or via an enterotomy and is guided through the small bowel with surgical assistance.
TECHNICAL CONSIDERATIONS
Certain general principles and techniques applicable to all forms of enteroscopy deserve consideration. Foremost, mucosal inspection should be accomplished during both
insertion and withdrawal because minor mucosal abrasions caused by instrumentation can mimic vascular or inflammatory lesions. Second, the use of fluoroscopy to assess
enteroscope and/or overtube position, and advancement varies and depends on many factors including the type of enteroscopy being performed, the approach (antegrade
vs retrograde), the indication, and endoscopist preference.
Although fluoroscopy was widely used previously, many endoscopists currently perform enteroscopy without fluoroscopic guidance. Finally, an important variable is the
use of CO2 for insufflation rather than air because studies specific to enteroscopy have shown enhanced insertion depth and better patient tolerance with CO2 insufflation.3-6 The technical specifications of push and deviceassisted enteroscopes and overtubes are listed in Tables 1 and 2.
Push enteroscopes
Push enteroscopy may be performed with dedicated enteroscopes or by using colonoscopes. Push enteroscopes are longer versions of standard endoscopes with a working
length of 200 to 250 cm, external diameters of 10.5 to 11.7 mm, and channel diameters of 2.8 to 3.8 mm. However, the length of the instrument does not necessarily correlate with deeper insertion or improved diagnostic yield.7 The use of overtubes has been proposed to allow for greater insertion depth during push enteroscopy; however, it is again unclear whether this results in a greater diagnostic yield.8-10 Overtubes are not routinely used because of greater patient discomfort and reported adverse events related to their use.9-12 Overtubes have been detailed in a separate ASGE Technology Committee document.13
Technique. The endoscope is introduced through the mouth and advanced into the small bowel as far as possible until looping limits forward progression. Torque
and withdrawal are performed to reduce loops, and the endoscope is then re-advanced and the process is repeated. If the endoscope cannot be advanced further
with these maneuvers, patient position can be changed and abdominal pressure can be applied. If a variablestiffness colonoscope is used, stiffening of the instrument
may allow further advancement. In procedures in which an overtube is used, it is backloaded up to the hub of the endoscope before insertion. The endoscope is then
advanced to the second or third portion of the duodenum, and loop reduction is then performed. The overtube is then advanced to the level of the tip of the endoscope,
and the endoscope is then re-advanced further. Fluoroscopy may guide loop reduction, assessment of endoscope position, and advancement.
Device-assisted enteroscopy
Double-balloon enteroscopes. DBE was first introduced in 2001 and was developed for evaluation of the entire jejunum and ileum. DBE uses a specially coupled enteroscope and overtube apparatus with latex balloons mounted on the distal ends of each component. The balloons are intended to anchor the endoscope in position during insertion to allow for pleating of the bowel over the endoscope shaft, reducing loop formation and allowing for greater insertion depth. Three DBE systems are currently available. The most commonly used system is an enteroscope with a 9.4-mm diameter, a 2.8-mm working channel, and a 200-cm working length (EN-450T5; Fujinon, Saitama, Japan). DBE systems designed with a smaller diameter (EN-450P5/20) and shorter length (EC-450BI5) are detailed in Table 1. The smaller diameter system may be used for pediatric patients and for diagnostic procedures in adults. The shorter length system has been used to perform ERCP in patients with postsurgical anatomy.
The soft overtube of the most commonly used DBE system (EN-450T5; Fujinon) has a length of 145 cm, an outer diameter of 13.2 mm, and a specifically designed pump for inflating and deflating the latex balloon at its tip. Additional available overtubes used with the smaller diameter and shorter length DBE enteroscopes are detailed in Table 2.
A balloon pump controller (PB-20; Fujinon) controls the internal dilation pressure of both enteroscope and overtube balloons, monitoring it and setting it at 5.6 kPa. Increased pressure within the balloon triggers an alarm. If the alarm is not acknowledged and silenced by the endoscopist or assistant, autodeflation of both balloons occurs.
Technique. DBE is a 2-person procedure, requiring an endoscopist and an assistant. After the overtube is loaded onto the enteroscope, a soft latex balloon is attached to the tip of the enteroscope. The balloons are deflated at the initiation of the procedure. For the antegrade approach, the endoscope and overtube are advanced to the duodenum past the major papilla, and the overtube balloon is inflated to maintain a stable position. The enteroscope is then advanced up to 40 cm distal to the overtube tip, and its balloon is inflated to anchor the enteroscope. The overtube balloon is then deflated, and the overtube is advanced toward the tip of the enteroscope. The overtube balloon is then reinflated such that the entire apparatus is secured to the intestine with both balloons inflated. The enteroscope-overtube apparatus is then retracted simultaneously so as to pleat the intestine along the overtube like an accordion. This sequence is repeated, and the device is advanced through the intestine in 40-cm increments (Fig. 1). When the desired or maximum insertion distance is reached, a submucosal tattoo is often placed to mark the distal extent of the evaluation.
Withdrawal of the apparatus is generally performed in short segments to allow for careful mucosal inspection. Withdrawal is initiated with the endoscope balloon inflated and the overtube balloon deflated. After withdrawal of the overtube, the overtube balloon is reinflated. Endoscope retraction is always performed with the overtube secured by its inflated balloon to prevent uncontrolled loss of depth of insertion.14,15 A circumferential white marking on the enteroscope 140 cm proximal to the balloon represents a marker beyond which the overtube should not be advanced or the enteroscope withdrawn. This is to prevent the overtube from shearing off the enteroscope balloon during insertion or withdrawal (Fig. 2). DBE was often performed previously with fluoroscopic guidance, although this is currently less commonly used.
For retrograde DBE, a colonoscopy preparation is required. The enteroscope and overtube are advanced to the cecum either directly or by using the previously described push-pull technique. With the overtube balloon inflated, the enteroscope is advanced across the ileocecal valve and its balloon inflated within the ileum. The overtube is then advanced into the ileum with its balloon deflated. Subsequently, the advancement steps are identical to those of the antegrade DBE technique previously described. DBE may allow complete enteroscopy, defined as endoscopic evaluation of the entire small bowel with a single approach or by combining antegrade and retrograde approaches.
Single-balloon enteroscopes. SBE was introduced in 2007, and it uses an enteroscope with an overtube (SIF-Q180; Olympus America Inc, Center Valley, Pa) and an electronic balloon inflation control device that allows automatic pressure control. In contrast to DBE, only the disposable overtube has a nonlatex balloon at its distal end. The enteroscope has a working length of 200 cm, an outer diameter of 9.2 mm, and a 2.8-mm diameter working channel. The overtube (ST-SB1; Olympus) is 140 cm long with a 13.2-mm outer diameter, and its distal end has an inflatable silicone balloon. The balloon is controlled by pressing buttons on the front panel of the Olympus balloon control unit or on a remote control. The balloon pressure is regulated to 5.4 kPa. The internal surface of the overtube is hydrophilic, and lubrication between the outer surface of the enteroscope and the inner surface of the overtube is facilitated by flushing the internal surface of the overtube with water.
Technique. The technique for SBE is similar to that for DBE. The overtube is backloaded onto the enteroscope, and the enteroscope is advanced as far as possible into
the small bowel, then anchored by using its flexible tip (as opposed to enteroscope tip balloon-assisted anchoring used in DBE). Subsequently, the overtube is advanced with its balloon deflated to the tip of the enteroscope. The overtube balloon is then inflated while keeping the enteroscope tip flexed. The entire apparatus is then withdrawn to allow pleating of the small bowel over the enteroscope and overtube. The enteroscope is then re-advanced while keeping the overtube balloon inflated to prevent slippage of the proximal bowel that has been pleated on the overtube. When the enteroscope cannot be advanced further, its tip is again flexed to anchor the enteroscope. The overtube balloon is then deflated, and the overtube is again advanced to the tip of the enteroscope. This sequence is repeated until the apparatus has advanced to the maximal, or to the desired extent within the small intestine (Fig. 3). The point of final enteroscope advancement can be marked with a submucosal tattoo.
Spiral enteroscopes. Spiral enteroscopy was developed in 2007 potentially to provide a simpler and faster technique compared with balloon-assisted enteroscopy. It uses a disposable overtube with a soft raised spiral ridge that is designed to pleat the small bowel. The overtube is 118 cm long with soft raised spiral helix at its distal end that is either 4.5 mm (low profile) or 5.5 mm (standard profile) in height. The overtube is compatible with enteroscopes that are 200 cm in length and between 9.1 and 9.5 mm in diameter. Two different overtubes are available for antegrade (Endo-Ease Discovery SB; Spirus Medical Inc, Stoughton, Mass) or retrograde (Endo-Ease Vista; Spirus Medical Inc) examinations. The overtube has a coupling device on its proximal end that affixes itself to the enteroscope. This allows for free rotation of the overtube independent of the enteroscope but prevents independent movement of the enteroscope (advancement or withdrawal) relative to the overtube. When the overtube is uncoupled, the enteroscope can then be advanced or withdrawn independent of the overtube. A motorized spiral enteroscopy system is in development.
Technique. Two operators are required to perform the procedure: an endoscopist and an assistant to operate the overtube. Before insertion, the inner lining of the overtube is generously lubricated with the proprietary lubricant supplied with the device. The overtube is then backloaded onto the enteroscope so that about 20 cm of the enteroscope protrudes past the distal tip of the overtube. When the overtube and enteroscope are coupled, the overtube should be rotated clockwise for advancement and counterclockwise for withdrawal. For antegrade examination, the overtube and enteroscope are advanced slowly with clockwise rotation of the overtube until the enteroscope tip ideally reaches the ligament of Treitz. It is important to minimize insufflation of air or CO2, which decreases the chance of loop formation in the stomach and allows for better contact of the spiral helix to the small intestine to initiate movement and pleating of the intestine onto the overtube. Resistance to rotation of the overtube is usually due to loop formation in the stomach. This can be countered by continued slow clockwise rotation of the overtube while gently pulling back (withdrawing) the overtube. This reduction maneuver along with application of external abdominal pressure or splinting can be used to advance the overtube-enteroscope unit into the small intestine. When resistance to further clockwise overtube rotation is encountered and deeper advancement is not thought to be possible, the enteroscope can be uncoupled from the overtube and further advanced to its maximal depth. Withdrawal of the enteroscope is performed by pulling back the enteroscope so that its tip is 20 cm distal to the overtube tip. At this point, it is recoupled, and further withdrawal is done by counterclockwise rotation of the overtube. For retrograde examinations, the technique is similar to antegrade examination.
On-demand enteroscope. The NaviAid (SMART Medical Systems Ltd, Ra’anana, Israel) is a newer device that consists of a disposable balloon component that is advanced through the working channel of an endoscope or colonoscope (NaviAid AB and NaviAid ABC) and an air supply unit. The NaviAid AB has a working length of 350 cm with a balloon diameter of 40 mm. The minimum endoscope working channel diameter needed for passage of the device is 3.8 mm. The inflation/deflation of the balloon is controlled by an air supply unit, and balloon pressure is regulated at 6 kPa. The balloon device can be advanced through the instrument channel of the endoscope only when deep enteroscopy is needed. It does not require any specific premounting or preprocedural preparation.
Technique. The procedure technique is conceptually similar to balloon-assisted enteroscopy with an overtube. The balloon is advanced beyond the tip of the endoscope through its instrument channel and inflated to anchor itself to the small intestine. Subsequently, repetitive push-pull maneuvers are performed with the endoscope sliding over the catheter as a rail until it reaches the inflated balloon distally. The balloon catheter can be removed to allow for therapeutic interventions as needed and reinserted for further advancement.
Intraoperative enteroscopy. Intraoperative enteroscopy is the most invasive of the enteroscopy techniques but can allow for complete evaluation of the small intestine. Due to significant advancements in noninvasive imaging and device-assisted enteroscopy, it is performed less frequently. The technique can be quite variable with regard to the location of endoscope insertion, the type of endoscope used, and the approach to intra-abdominal access (laparotomy vs laparoscopy). It is performed in the operating room with the assistance of a surgical team while the endoscopist performs the enteroscopy. The surgeon pleats segments of intestine over the enteroscope via a laparotomy or with laparoscopic techniques. Lesions can be treated endoscopically or marked for surgical resection.
INDICATIONS
The most common indication for all types of enteroscopy is the diagnosis and/or therapy of obscure overt or occult intestinal bleeding, ie, bleeding without an etiology found on standard upper endoscopy and colonoscopy with terminal ileoscopy.8 Other indications include evaluation of imaging abnormalities raising concern for small-bowel Crohn’s disease, strictures, ulcers, celiac disease, malabsorption, polyps, masses, lymphoma, and other infiltrative diseases.24-30 Therapeutic indications in addition to hemostasis include polypectomy, retrieval of foreign bodies, enteral stricture dilation, placement of jejunal feeding tubes, treatment of early postoperative small-bowel obstruction, and performance of ERCP in patients with postsurgical anatomy.
EFFICACY AND COMPARATIVE STUDIES
Push enteroscopy
Push enteroscopy offers the advantage of wide availability because it does not require specialized equipment or training. Currently, it is usually performed for investigation of upper small-bowel lesions up to the proximal jejunum as determined by previous imaging or not within reach of standard EGD. The average depth of intubation at push enteroscopy can be estimated from reports without standardized methodologies. The extent of jejunal intubation has been reported to be approximately 45 to 60 cm beyond the ligament of Treitz with a colonoscope, 25 to63 cm with an enteroscope, and 46 to 80 cm with an enteroscope through an overtube.7,9,35-42 The diagnostic yield of push enteroscopy for obscure GI bleeding ranges from 20% to 80%.43 However, many lesions found during push enteroscopy are within reach of a standard gastroscope,44 and the true diagnostic yield of push enteroscopy may be more in the 15% to 40% range.45 Overt bleeding has been found to be predictive for positive findings at push enteroscopy, which can change management in 40% to 75% of patients in this setting.46-51 Studies evaluating long-term outcomes of patients undergoing push enteroscopy have shown conflicting results. One study indicated that recurrent rebleeding occurs in 33% of patients, with a trend toward frequent rebleeding in patients with angioectasias.52 Some studies indicate that therapy of angioectasias can reduce transfusion requirements and improve quality of life,50,53-55 but others have not shown similar results.
Several studies compared push enteroscopy with WCE. In compiled comparative studies that included 216 patients with bleeding of unknown origin or suspected small-bowel disease, a diagnosis was made with push enteroscopy in 29% of patients and with WCE in 68% of patients.38-40,58-60 Clinical management was changed in 9% and 39% of patients diagnosed with push enteroscopy and WCE, respectively.39,40,58 In 2 series, all lesions diagnosed by push enteroscopy were also seen by WCE, but most of the lesions seen by WCE and not by push enteroscopy were distal to the reach of the enteroscope.39,58 However, in a study of patients with familial adenomatous polyposis, push enteroscopy detected many more polyps than WCE, even though the latter examined far more of the intestine. WCE did not visualize the ampulla of Vater in all patients and missed many polyps larger than 10 mm as well as large submucosal tattoos.61 In a separate study with follow-up of 1 year or more after diagnosing small-bowel disease, the sensitivity and specificity of push enteroscopy were 48% and 80%, respectively, and for WCE, they were 92% and 69%, respectively (P < .01).62
Meta-analysis data also indicate that capsule endoscopy is superior to push enteroscopy for the diagnosis of smallbowel pathology, with a 35% to 40% incremental yield and a number needed to treat of 3.
Double-balloon enteroscopy
Most published data on balloon-assisted enteroscopy come from DBE studies. Most studies have focused on patients with obscure GI bleeding, but a few have compared
DBE with other small-bowel imaging modalities.14,15,24,28,42,65-73 The mean reported procedure times range from 73 to 123 minutes.24,65,71,74,75 The estimated depth of insertion for the antegrade approach is reported to be between 220 to 360 cm and for the retrograde approach between 124 to 183 cm.24,65,71,74,75 Reported rates of complete enteroscopy vary widely. Whereas Japanese studies have reported complete enteroscopy rates in the 70% to 86% range, Western series have generally reported lower rates.14,65,74-80 Reported diagnostic yields have ranged from 40% to 80%, with therapeutic yields of 15% to 55%.24,65,71,74,75,81 A large study of 2245 DBEs performed in 1765 patients revealed that diagnostic yield varied with the indication. Rates were highest for patients with PeutzJeghers syndrome and lowest when the indication for the procedure was diarrhea.79 In patients with angioectatic lesions, DBE has been shown to allow effective treatment, although recurrent bleeding is common.82,83 In 1 study of 50 patients, 88% of whom were treated for angioectasias and followed for a mean duration of 55 months, mean hemoglobin levels increased from a pretreatment level of 7.6 to 11.0 g/dL after treatment. There was an associated significant decrease in transfusion requirements. However, the rebleeding rate was 48% in patients treated with argon plasma coagulation.82 In another study of 98 patients with treated angioectasias, rebleeding occurred in 46% of patients at 36 months. Factors associated with increased rates of rebleeding were the presence of a larger number of angioectasias and underlying cardiac disease.83
Some studies compared DBE with capsule endoscopy and push enteroscopy. A comparative meta-analysis of DBE and capsule endoscopy indicated a similar yield of clinically significant small-bowel findings (60% and 57%).84 Comparison of DBE and push enteroscopy indicates a superior diagnostic yield with DBE that is thought to be related to higher rates of complete small-bowel visualization.
Single-balloon enteroscopy
The efficacy of SBE is generally similar to that of DBE. Reported diagnostic yields have ranged from 41% to 65% and therapeutic yields from 7% to 50%.85-94 The reported range for depth of insertion is 133 to 270 cm for antegrade examinations and 73 to 199 cm for retrograde examinations.86,89,91,92,94 Studies suggest that the rate of total enteroscopy with SBE may be lower than that with DBE by 0% to 24%.86-88,93 This may be because of the difficulty in maintaining enteroscope position in the small bowel as the overtube is advanced due to lack of a specific anchoring mechanism for the SBE enteroscope.
Spiral enteroscopy
Reports on spiral enteroscopy suggest decreased procedure times compared with balloon-assisted enteroscopy.92,95-99 Data from 3 studies including a total of 183 patients (of whom 171 successfully underwent the procedure) indicated mean depths of insertion ranging from 175 to 262 cm, mean procedure times of 34 to 37 minutes,
and diagnostic yields of 12% to 59%.95-97 With regard to diagnostic yield, in 1 of these studies, the primary indication was diarrhea; hence, the diagnostic yield was low at 12%.96 The other 2 studies indicated diagnostic yields of 33% and 59%.95,97
A comparison study of WCE and spiral enteroscopy in 56 patients who had positive capsule findings indicated that the yield of spiral enteroscopy was 54%. The type of finding on capsule endoscopy was associated with reproducibility on spiral enteroscopy, with fresh bleeding being the most reproducible, followed by angioectasias.100 Another study that examined long-term outcomes in 78 patients who underwent spiral enteroscopy for obscure GI bleeding found that deep small-bowel spiral enteroscopy was safe and effective and led to a statistically significant reduction in the incidence of overt bleeding from 62% to 26%.101
