ASGE members may submit coding inquiries electronically to codingquestions@asge.org. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Below is our featured Coding Question of the Month that could be beneficial to your practice.

Question

The patient has a J-pouch, and the physician states in his procedure notes that the scope was advanced through the anus to the ileorectal anastomosis, and “J-Pouch seen, Ileum” (exact words in the notes). Biopsies were taken in the distal ileum. He codes it as a pouchoscopy CPT Code 44386, but his procedure notes state it is a flexible sigmoidoscopy with biopsy. 

Answer

A J-pouch involves joining the small intestine directly to the anal canal after removal of parts of the large intestine. Some patients will have direct ileo-anal anastomosis. Per CPT instructions, "Report pouch endoscopy codes 44385 and 44386 for endoscopic examination of a patient who has undergone resection of the colon with ileo-anal anastomosis (e.g., J-Pouch)." If biopsies are done, code 44386 would be reported.