How To Use CPT Code 45332

CPT 45332 describes the procedure of sigmoidoscopy with the removal of foreign bodies. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45332?

CPT 45332 can be used to describe the procedure of sigmoidoscopy with the removal of foreign bodies. This code is used when a healthcare provider examines the rectum and colon using a flexible colonoscope, and identifies and removes foreign bodies that may obstruct or damage the intestine.

2. Official Description

The official description of CPT code 45332 is: ‘Sigmoidoscopy, flexible; with removal of foreign body(s).’ It is important to note that CPT code 45332 should not be reported in conjunction with CPT code 45330. If fluoroscopic guidance is performed during the procedure, CPT code 76000 should be used.

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring appropriate prepping and anesthesia.
2. The provider inserts a sigmoidoscope through the anus and advances it into the anal canal, rectum, and sigmoid colon.
3. Using the sigmoidoscope, the provider examines a portion of the descending colon up to the splenic flexure.
4. The provider inspects the sigmoid colon for the presence of foreign bodies.
5. If foreign bodies are identified, the provider introduces forceps or a snare through the working channel of the sigmoidoscope and removes the foreign bodies.
6. Once the foreign bodies are removed, the provider withdraws the sigmoidoscope and removes all instruments.

4. Qualifying circumstances

CPT 45332 is used when a healthcare provider performs sigmoidoscopy with the specific purpose of removing foreign bodies from the sigmoid colon. Foreign bodies can include objects that have been swallowed and traveled to the lower gastrointestinal tract, or objects that have been inserted through the anus and rectum. The procedure is typically performed on patients who have experienced traumatic injury or have ingested foreign bodies.

5. When to use CPT code 45332

CPT code 45332 should be used when a healthcare provider performs sigmoidoscopy with the explicit intention of removing foreign bodies from the sigmoid colon. It is important to note that this code should not be reported in conjunction with CPT code 45330, which describes a different procedure.

6. Documentation requirements

To support a claim for CPT 45332, the healthcare provider must document the following information:

• Reason for performing the sigmoidoscopy and the need for foreign body removal
• Details of the procedure, including the use of a flexible colonoscope and the removal of foreign bodies
• Date and time of the procedure
• Specific foreign bodies identified and removed
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 45332, ensure that the procedure involves the removal of foreign bodies from the sigmoid colon using a flexible sigmoidoscope. It is important to note that CPT code 45332 should not be reported in conjunction with CPT code 45330. If fluoroscopic guidance is performed during the procedure, CPT code 76000 should be used.

8. Historical information

CPT 45332 was added to the Current Procedural Terminology system on January 1, 1990. The code was later changed on January 1, 2015, with the addition of the description ‘with removal of foreign body.’

9. Examples

1. A healthcare provider performing sigmoidoscopy with the removal of a swallowed coin from the sigmoid colon.
2. A patient presenting with rectal bleeding undergoes sigmoidoscopy, during which a foreign body is discovered and removed from the sigmoid colon.
3. A healthcare provider performs sigmoidoscopy on a patient who has accidentally ingested a small toy, successfully removing it from the sigmoid colon.
4. During a routine sigmoidoscopy, a healthcare provider identifies and removes a fishbone that had become lodged in the sigmoid colon.
5. A patient with a history of ingesting foreign objects undergoes sigmoidoscopy, during which multiple small objects are found and removed from the sigmoid colon.
6. A healthcare provider performs sigmoidoscopy on a patient who has inserted a foreign object through the anus, successfully removing it from the sigmoid colon.
7. During a sigmoidoscopy, a healthcare provider identifies and removes a piece of broken glass that had been causing discomfort in the sigmoid colon.
8. A patient with a history of trauma undergoes sigmoidoscopy, during which a foreign body is discovered and removed from the sigmoid colon.
9. A healthcare provider performs sigmoidoscopy on a patient who has accidentally swallowed a small battery, successfully removing it from the sigmoid colon.
10. During a routine sigmoidoscopy, a healthcare provider identifies and removes a small metal fragment that had been causing pain in the sigmoid colon.