How To Use CPT Code 45333

CPT 45333 describes the procedure of sigmoidoscopy with the removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps. 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 45333?

CPT 45333 is used to describe a specific procedure called sigmoidoscopy with the removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps. This code is used when a healthcare provider uses a flexible colonoscope to examine the rectum and sigmoid colon and identifies and removes abnormal tissue or lesions using hot biopsy forceps.

2. Official Description

The official description of CPT code 45333 is: ‘Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.’ It is important to note that CPT code 45333 should not be reported in conjunction with CPT code 45330.

3. Procedure

1. The healthcare provider inserts a flexible sigmoidoscope through the anus and advances it to the anal canal, rectum, and sigmoid colon.
2. Using the scope, the provider examines the internal surface of the sigmoid colon for the presence of abnormal tissue or lesions.
3. If any tumors, polyps, or other lesions are identified, the provider introduces hot biopsy forceps through a channel in the scope.
4. The provider uses the hot biopsy forceps to grasp and excise each lesion.
5. To prevent bleeding, the provider administers electrical current through the hot biopsy forceps, cauterizing or heat sealing the tissues.
6. The excised specimens are sent to a laboratory for analysis.
7. Finally, the provider removes all instruments and withdraws the sigmoidoscope.

4. Qualifying circumstances

CPT 45333 is performed on patients who require the removal of tumor(s), polyp(s), or other lesion(s) in the sigmoid colon. The procedure is typically done when the patient is appropriately prepped and anesthetized. It is important to note that CPT code 45333 should not be reported in conjunction with CPT code 45330.

5. When to use CPT code 45333

CPT code 45333 should be used when a healthcare provider performs a sigmoidoscopy and removes tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps. It is important to note that CPT code 45333 should not be reported in conjunction with CPT code 45330.

6. Documentation requirements

To support a claim for CPT code 45333, the healthcare provider must document the following information:

• Patient’s diagnosis necessitating the sigmoidoscopy and removal of tumor(s), polyp(s), or other lesion(s)
• Details of the procedure, including the use of hot biopsy forceps
• Date of the procedure
• Any complications or additional findings during the procedure
• Results of the analysis of the excised specimens, if available
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 45333, ensure that the procedure involves the removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps. It is important to note that CPT code 45333 should not be reported in conjunction with CPT code 45330. Additionally, it is recommended to use CPT code 45338 when the provider removes tumors, polyps, or other lesions using a snare technique.

8. Historical information

CPT code 45333 was added to the Current Procedural Terminology system on January 1, 1990. The code was later updated on January 1, 2015 to include the use of hot biopsy forceps or bipolar cautery for the removal of tumor(s), polyp(s), or other lesion(s).

9. Examples

1. A gastroenterologist performs a sigmoidoscopy on a patient with a suspected polyp in the sigmoid colon. During the procedure, the gastroenterologist identifies and removes the polyp using hot biopsy forceps.
2. A colorectal surgeon performs a sigmoidoscopy on a patient with a known tumor in the rectum. Using hot biopsy forceps, the surgeon removes the tumor during the procedure.
3. An oncologist performs a sigmoidoscopy on a patient with a history of colon cancer. During the procedure, the oncologist identifies and removes a suspicious lesion using hot biopsy forceps.
4. A general surgeon performs a sigmoidoscopy on a patient with chronic rectal bleeding. The surgeon identifies and removes a polyp using hot biopsy forceps during the procedure.
5. A gastroenterologist performs a sigmoidoscopy on a patient with ulcerative colitis. During the procedure, the gastroenterologist identifies and removes a small lesion using hot biopsy forceps.
6. A proctologist performs a sigmoidoscopy on a patient with a history of anal polyps. Using hot biopsy forceps, the proctologist removes the polyps during the procedure.
7. A gastroenterologist performs a sigmoidoscopy on a patient with a suspected tumor in the sigmoid colon. During the procedure, the gastroenterologist identifies and removes the tumor using hot biopsy forceps.
8. A colorectal surgeon performs a sigmoidoscopy on a patient with a known polyp in the rectum. Using hot biopsy forceps, the surgeon removes the polyp during the procedure.