How To Use CPT Code 45309

CPT 45309 describes the procedure of proctosigmoidoscopy with the removal of a single tumor, polyp, or other lesion using the snare technique. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45309?

CPT 45309 is used to describe the proctosigmoidoscopy procedure, which involves the examination of the anus, rectum, and sigmoid colon using a rigid proctosigmoid scope. During this procedure, the provider removes a single tumor, polyp, or other lesion using the snare technique. The snare technique involves using a wire loop to shave off the abnormal tissue.

2. Official Description

The official description of CPT code 45309 is: ‘Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique.’

3. Procedure

1. The provider inserts a rigid proctosigmoid scope through the anus and advances it to the anal canal, rectum, and sigmoid colon.
2. The provider inspects the internal surface of the area for the presence of abnormal tissue or a lesion.
3. Using the snare technique, the provider passes a wire loop over the predetermined, marked polyp or lesion and shaves off the abnormal tissue.
4. Once the procedure is complete, the provider withdraws the scope.

4. Qualifying circumstances

CPT 45309 is used when a provider performs a proctosigmoidoscopy and removes a single tumor, polyp, or other lesion using the snare technique. This code is appropriate for cases where only one abnormality is removed during the procedure.

5. When to use CPT code 45309

CPT code 45309 should be used when a provider performs a proctosigmoidoscopy and removes a single tumor, polyp, or other lesion using the snare technique. It is important to ensure that only one abnormality is removed during the procedure to accurately report this code.

6. Documentation requirements

To support a claim for CPT 45309, the provider must document the following information:

• Description of the single tumor, polyp, or lesion removed
• Details of the snare technique used
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 45309, ensure that the procedure involves the removal of a single tumor, polyp, or lesion using the snare technique. It is important to accurately document the details of the procedure to support the claim. Additionally, be aware of other codes that may be appropriate for different techniques used in the removal of tumors, polyps, or lesions.

8. Historical information

CPT 45309 was added to the Current Procedural Terminology system on January 1, 1994. There have been no updates to the code since its addition.

9. Examples

1. A gastroenterologist performs a proctosigmoidoscopy and removes a single polyp using the snare technique.
2. A colorectal surgeon performs a proctosigmoidoscopy and removes a single tumor using the snare technique.
3. An oncologist performs a proctosigmoidoscopy and removes a single lesion using the snare technique.
4. A general surgeon performs a proctosigmoidoscopy and removes a single tumor using the snare technique.
5. A gastroenterologist performs a proctosigmoidoscopy and removes a single polyp using the snare technique.
6. A colorectal surgeon performs a proctosigmoidoscopy and removes a single tumor using the snare technique.
7. An oncologist performs a proctosigmoidoscopy and removes a single lesion using the snare technique.
8. A general surgeon performs a proctosigmoidoscopy and removes a single tumor using the snare technique.
9. A gastroenterologist performs a proctosigmoidoscopy and removes a single polyp using the snare technique.
10. A colorectal surgeon performs a proctosigmoidoscopy and removes a single tumor using the snare technique.