Codonopsis pilosula is a commonly used herbal medicine with edible value in people’s daily life and has tonifying effect. Polysaccharide as one of the main active components of C. pilosula has a variety of biological activities. In recent years, scholars have achieved remarkable progress in the study of C. pilosula polysaccharide in the treatment of intestinal diseases. The studies have demonstrated that intestinal flora may be a target for C. pilosula polysaccharide in the treatment of intestinal diseases. This paper summarizes the role of C. pilosula polysaccharide in the regulation of intestinal microecology and intestinal diseases, aiming to provide a theoretical and experimental basis for the development of C. pilosula polysaccharide as a prebiotic preparation and the treatment of intestinal diseases.