45378 cpt code

45378 CPT Code (2022) – Description, Guidelines, Reimbursement, Modifiers & Examples

45378 CPT code is used for billing services when flexible Colonoscopy is performed by brushing or washing.

The colonoscope is introduced into the patient’s body via the rear passage and traverses through the whole colon to the cecum to visualize the lumen of the colon and rectum. The colonoscope will be removed after the completion of the procedure.

45378 CPT Code Description

45378 CPT code also included specimen collection or testing like biopsies. Colonoscopy CPT code 45378 is usually performed for the following reasons:

  • To detect intestinal signs and symptoms such as rectal bleeding, Chronic constipation, other intestinal disorders, abdominal pain, and chronic diarrhea.
  • To identify polyps or remove pf polyps in the large intestine.
  • Colonoscopy is also performed for screening purposes, while patients above 50 have higher chances of colon cancer. Physicians usually recommend Colon screening every ten years or earlier to detect colon cancer.

Suppose screening Colonoscopy is performed for an individual at higher risk of colon cancer or has a strong family and personal history of colorectal cancer. In that case, it will be performed every three years while at average risk every ten years.

Medicare does accept CPT code 45378, and it will be reported the G codes, like G0105 for Colorectal cancer screening at high risk or G0121 will be noted when the patient does not meet the criteria for high risk.

45378 CPT code will be reported when Colonoscopy is performed, which includes:

  • Flexible
  • Diagnostic
  • Collection of specimens by brushing or washing
cpt 45378

45378 CPT Code Billing Guidelines

45378 CPT code includes bleeding control if bleeding occurs due to the endoscopic procedure during the same operative session.

CPT 45378 includes the entire colon if it examines from the rectum to Cecum or terminal ilium when performed

Modifier 73 is appropriate to attach with CPT 45378 when the Colonoscopy procedure is terminated before the administration of anesthesia, and insurance will pay 50% for this service. In comparison, modifier 74 will be appended with CPT 45378 if the procedure is terminated after anesthesia, and insurance will pay 100% for this service.

If Colonoscopy procedure 45378 is not completed due to any circumstances and the physician plans to repeat the Colonoscopy, modifier 53 is appropriate to attach with CPT 45378. While modifier 52 is only applicable if the physician terminates the procedure and cannot perform again due to the patient’s current condition or any other reason, it is appropriate to bill CPT 45378 with modifier 52.

CPT codes 45379-45393, 45388, and 45398 (Colonoscopy flexible) are not allowed to bill together on the same date of service in conjunction with CPT 45378, and the modifier is also not allowed according to NCCI (National Correct Coding Initiative).

45378 CPT code (Colonoscopy) is primarily a more complex procedure; it is not separately reportable. It is only reportable when performed alone or for an unrelated condition with appropriate modifier 59 or XP, XE, XU, XS.

If computed tomographic Colonography (CPT codes 74261-74263) is performed, these codes are separately reportable with CPT code 45378.

Surgical endoscopy always includes diagnostic Colonoscopy, and it is not separately reportable.

Medicare or other insurances cover HCPCS level II codes G0105 or G0121 instead of CPT code 45378.

If diagnostic Colonoscopy is performed and the physician cannot reach the splenic flexure, it will be reported with CPT code 45330 instead of CPT 45378. While the physician reaches the splenic flexure but not to the Cecum, it would be appropriate to bill CPT 45378 with modifier 53. If Cecum is also reviewed and able to reach that point, CPT 45378 will be reported without any modifier. 

Therapeutic Colonoscopy procedures are reported with different CPT codes (45331 – 45347, 45379 – 45398) instead of CPT 45378.

If a colonic decompression procedure is performed, it would be reported with CPT 45393 instead of 45378. CPT 45378 is not allowed to bill together with CPT 45378.

Documentation should support the medical necessity and reflect the patient’s current condition to perform this service.

Modifiers

The following list contains modifiers that are applicable with 45378 CPT code:

  • PT, 22, 23, 33, 47,51, 52, 53, 58, 59, 63, 73, 74, 76, 77, 78, 79, 99, AI, AQ, AR, CC, CR, EY, ET, Q5, Q6, QJ, SG, XE, XU, XP, XE, XS, GA, GC, GJ, GK, GR, GU, GY, GZ, KX

Modifier PT will be appended with CPT 45378 when Screening coloscopy is converted into diagnostic Colonoscopy due to incidental findings such as colon polyps for Medicare insurance. In contrast, modifier 33 will be applicable for commercial insurances.

For example, the patient came to the physician for routine screening for Colonoscopy, and it revealed colon polyps. The physician changed the screening Colonoscopy into diagnostic for polyp removal or biopsy. It would be code like 45378-PT, Z12.11, and K63.5.

Modifier 52 is applicable with CPT 45378 when an incomplete Colonoscopy is performed with complete Colonoscopy preparation. In contrast, modifier 53 will be attached if Colonoscopy is terminated and the physician plans to redo Colonoscopy in the future.

Modifier 59 is applicable with CPT code 45378 if any other procedure is done in combination with these services that are generally not billed together on the same date of service, then modifier 59 will be appropriate while modifier 51 is applicable when the other procedure is not the component of CPT code 45378

Modifier 23 is applicable with 45378 CPT code if general or local anesthesia is given to patients who usually are not required for the procedure. 

Modifier 76 will be attached to CPT code 45378 if service is repeated by the same physician on the same date of service, while modifier 77 if the procedure has been done on the same date service by a different physician, respectively.

Modifier 78 will be appended with CPT code 45378 if the procedure is repeated with the exact condition of the global period. In contrast, modifier 79 is applicable when the procedure is reported for an unrelated condition.

cpt code 45378

Reimbursement

A maximum of 1 unit can be billed in the day for 45378 CPT code and 3 units if the document supports the medical necessity of the exam. The cost and RUVS of CPT 45378 are as follows:

  • Facility Price: Cost $199.46 RUVS 5.76378
  • Non-Facility Price: Cost $357.14 RUVS 11.54478

CPT 45378 Examples

Below are examples of when a Colonoscopy service (CPT 45378) will be performed:

Example 1

A 20-year-old male presents to the office with a severe headache, nausea, approximately eight episodes of non-bloody vomiting, and around three episodes of non-bloody diarrhea with severe body aches since this morning. He also had a family history of colon cancer.

He denies fever, chills, urinary complaints, chest pain, cough, back pain, recent travel. Patient conditions were not better by giving medications, and pain became worse in the upper abdominal region. He denies any weight changes and no jaundice.

The patient was unable to eat or drink anything. The physician decided to do a Colonoscopy to diagnose the problem better. Colonoscopy revealed that the patient has Colon Polyps. 

Example 2 

A 51 years-old male who denies any past medical history presents to ED (Emergency Dept) with lower abdominal x 5 days on and off, primarily constant now, burning in nature, 9 out of 10, and worse on exertion.

He cannot keep down any food and denies shortness of breath, diaphoresis, nausea, vomiting, cough, hemoptysis, palpitations, leg pain, or swelling. There is no excessive belching, flatus, diarrhea, constipation, fever, or chills. Physical exams revealed that pain is related to the colon despite heart-related and differential dx being colitis.

Diagnostic studies like CT and MRI of the abdomen and pelvis region revealed severely inflamed large intestine. The doctor consulted with a Gerontologist, and he suggested doing a Colonoscopy to treat the inflamed large intestine. The patient placed an appointment with a gastroenterologist for Colonoscopy. 

Example 3 

Since this morning, a 47-year-old female has presented to the emergency department with generalized abdominal pain, chronic constipation, nausea, vomiting, and diarrhea. The patient states that she woke up this morning with symptoms and has had many episodes of bilious vomiting and had bloody watery diarrhea since this morning.

She says that she never faced any problem previously. She denies numbness, tingling, headache, itching. The physician performed diagnostic studies to reveal the problem and ordered IV fluids, Pepcid, Toradol, Zofran to treat diarrhea and pain.

The pain was getting worse after medications. Physical exam revealed that differential dx are Appendicitis, gastritis, colitis, diverticulitis. The physician decided to do a Colonoscopy after consulting with a GI specialist. CPT and MRI of the abdomen show abnormal findings. 

Example 4 

A 13-year-old male presents to the emergency department with no significant past medical history after accidentally swallowing a coin and being stuck in the ascending colon. He is unable to eat or drink anything for 5 hours. He had a choking sensation and was unable to breathe correctly.

Physical exam revealed that the patient had a foreign body at descending colon while the rest of the systems were reviewed and negative. The physician orders a chest x-ray to confirm the position of the foreign body in the stomach. The physician tried to remove the foreign body with tools but could not move the coin to the intestine.

The patient was seen by a gastroenterologist and planned to do a colonoscopy to remove a foreign body. A colonoscopy procedure was done to pass the coin to the intestine and will be automatically removed by a bowel movement. The colonoscopy procedure was done successfully, and patient conditions became stable. 

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