How To Use CPT Code 45315

CPT 45315 describes the procedure of proctosigmoidoscopy with the removal of multiple tumors, polyps, or other lesions using hot biopsy forceps, bipolar cautery, or a 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 45315?

CPT 45315 is used to describe a specific procedure called proctosigmoidoscopy. During this procedure, a healthcare provider uses a rigid proctosigmoidoscope, which is a short instrument with a camera, to examine the inner part of the anus, rectum, and sigmoid colon. The provider then removes multiple tumors, polyps, or other lesions using techniques such as hot biopsy forceps, bipolar cautery, or a snare.

2. Official Description

The official description of CPT code 45315 is: ‘Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery, or snare technique.’

3. Procedure

1. After appropriate preparation and anesthesia, the healthcare provider inserts a rigid proctosigmoidoscope through the anus and advances it to the anal canal, rectum, and sigmoid colon.
2. The provider carefully inspects the internal surface of the area to identify any abnormal tissue or lesions.
3. Using techniques such as hot biopsy forceps, bipolar cautery, or a snare, the provider removes or destroys the identified tumors, polyps, or lesions.
4. If using hot biopsy forceps or bipolar cautery, the provider applies high-frequency electric current to cauterize or destroy the abnormal tissue.
5. If using a snare technique, the provider passes a wire loop over the marked polyp or lesion and shaves it off.
6. Once the procedure is complete, the provider withdraws the proctosigmoidoscope.

4. Qualifying circumstances

CPT 45315 is performed on patients who require the removal of multiple tumors, polyps, or other lesions in the anus, rectum, and sigmoid colon. The procedure is typically done by a healthcare provider who is trained in proctosigmoidoscopy and has the necessary equipment and expertise to perform the removal using hot biopsy forceps, bipolar cautery, or a snare technique.

5. When to use CPT code 45315

CPT code 45315 should be used when a healthcare provider performs proctosigmoidoscopy and removes multiple tumors, polyps, or other lesions using hot biopsy forceps, bipolar cautery, or a snare technique. It is important to accurately document the procedure and the number of tumors, polyps, or lesions removed.

6. Documentation requirements

To support a claim for CPT 45315, the healthcare provider must document the following information:

• Indication for the procedure and the need for removal of multiple tumors, polyps, or lesions
• Details of the procedure, including the use of hot biopsy forceps, bipolar cautery, or a snare technique
• Number and location of the tumors, polyps, or lesions removed
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 45315, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the removal of multiple tumors, polyps, or lesions using hot biopsy forceps, bipolar cautery, or a snare technique. Additionally, follow any specific guidelines provided by the payer or coding guidelines for proper reporting of the procedure.

8. Historical information

CPT code 45315 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A gastroenterologist performs proctosigmoidoscopy on a patient and removes multiple polyps using hot biopsy forceps.
2. A colorectal surgeon performs proctosigmoidoscopy on a patient and removes multiple tumors using bipolar cautery.
3. An oncologist performs proctosigmoidoscopy on a patient and removes multiple lesions using a snare technique.
4. A general surgeon performs proctosigmoidoscopy on a patient and removes multiple polyps using a combination of hot biopsy forceps and bipolar cautery.
5. A gastroenterologist performs proctosigmoidoscopy on a patient and removes multiple tumors using a combination of bipolar cautery and a snare technique.
6. A colorectal surgeon performs proctosigmoidoscopy on a patient and removes multiple lesions using a combination of hot biopsy forceps and a snare technique.
7. An oncologist performs proctosigmoidoscopy on a patient and removes multiple polyps and tumors using hot biopsy forceps, bipolar cautery, and a snare technique.
8. A general surgeon performs proctosigmoidoscopy on a patient and removes multiple polyps and lesions using hot biopsy forceps, bipolar cautery, and a snare technique.
9. A gastroenterologist performs proctosigmoidoscopy on a patient and removes multiple tumors and lesions using hot biopsy forceps, bipolar cautery, and a snare technique.
10. A colorectal surgeon performs proctosigmoidoscopy on a patient and removes multiple polyps, tumors, and lesions using hot biopsy forceps, bipolar cautery, and a snare technique.