How To Use CPT Code 45331

CPT 45331 describes the procedure of sigmoidoscopy with biopsy, which involves the examination of the rectum and sigmoid colon using a flexible sigmoidoscope. 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 45331?

CPT 45331 is a code used to describe the procedure of sigmoidoscopy with biopsy. It involves the use of a flexible sigmoidoscope, a narrow tube with a camera, to examine the inner part of the rectum and the sigmoid colon. During this procedure, the provider may also take one or more biopsies from the colon for further examination.

2. Official Description

The official description of CPT code 45331 is: ‘Sigmoidoscopy, flexible; with biopsy, single or multiple.’ It is important to note that CPT code 45331 should not be reported in conjunction with CPT code 45349 for the same lesion.

3. Procedure

1. During the sigmoidoscopy procedure, the provider inserts a flexible sigmoidoscope through the anus and advances it to the anal canal, rectum, and sigmoid colon.
2. The provider carefully inspects the sigmoid colon for any abnormal tissue or lesions.
3. If any suspicious areas are identified, the provider may take one or more tissue samples, known as biopsies, for further examination.
4. Once the procedure is complete, the provider withdraws the sigmoidoscope.

4. Qualifying circumstances

CPT 45331 is typically performed on patients who require an examination of the rectum and sigmoid colon. It may be used to investigate symptoms such as rectal bleeding, changes in bowel habits, or to screen for colorectal cancer. The procedure is performed by a qualified healthcare provider who is trained in performing sigmoidoscopies and biopsies.

5. When to use CPT code 45331

CPT code 45331 should be used when a sigmoidoscopy procedure with biopsy is performed on a patient. It is important to note that CPT code 45331 should not be reported in conjunction with CPT code 45349 for the same lesion.

6. Documentation requirements

To support a claim for CPT code 45331, the healthcare provider must document the following information:

• Reason for performing the sigmoidoscopy procedure
• Details of the biopsy, including the number of biopsies taken
• Any abnormal findings or lesions identified during the procedure
• Procedure start and end times
• Any complications or adverse events that occurred
• Provider’s signature

7. Billing guidelines

When billing for CPT code 45331, ensure that the procedure performed is a sigmoidoscopy with biopsy. It is important to follow the guidelines and not report CPT code 45331 in conjunction with CPT code 45349 for the same lesion. Additionally, consider any specific billing requirements or modifiers that may be necessary based on the payer’s guidelines.

8. Historical information

CPT code 45331 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 a sigmoidoscopy with biopsy on a patient with rectal bleeding to investigate the cause of the symptoms.
2. A primary care physician performs a sigmoidoscopy with biopsy as part of a routine colorectal cancer screening for a patient over the age of 50.
3. A gastroenterologist performs a sigmoidoscopy with biopsy on a patient with a family history of colorectal cancer to assess their risk.
4. A gastroenterologist performs a sigmoidoscopy with biopsy on a patient with chronic diarrhea to evaluate for inflammatory bowel disease.
5. A gastroenterologist performs a sigmoidoscopy with biopsy on a patient with a known polyp to monitor its growth and assess for any changes.
6. A gastroenterologist performs a sigmoidoscopy with biopsy on a patient with unexplained weight loss and abdominal pain to investigate potential underlying causes.
7. A gastroenterologist performs a sigmoidoscopy with biopsy on a patient with a history of ulcerative colitis to monitor for any signs of disease progression or complications.
8. A gastroenterologist performs a sigmoidoscopy with biopsy on a patient with iron deficiency anemia to investigate potential gastrointestinal bleeding sources.
9. A gastroenterologist performs a sigmoidoscopy with biopsy on a patient with a positive fecal occult blood test to determine the source of the blood.
10. A gastroenterologist performs a sigmoidoscopy with biopsy on a patient with a suspected rectal tumor to obtain tissue samples for further examination and diagnosis.