How To Use CPT Code 45335

CPT 45335 describes the procedure of sigmoidoscopy with directed submucosal injection(s) using a flexible endoscope. 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 45335?

CPT 45335 is used to describe the procedure of sigmoidoscopy with directed submucosal injection(s) using a flexible endoscope. This code is used when a healthcare provider inserts a flexible endoscope into the anus and navigates it to the rectum and lower (sigmoid) colon. During the procedure, the provider performs one or more injections into the submucosa, which is the tissue below the mucous membrane.

2. Official Description

The official description of CPT code 45335 is: ‘Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance.’ It is important to note that CPT code 45335 should not be reported in conjunction with CPT codes 45334 and 45349 for the same lesion, or with CPT code 45330.

3. Procedure

1. The healthcare provider ensures that the patient is appropriately prepped and anesthetized.
2. A flexible endoscope is inserted into the anus and maneuvered to the rectum and sigmoid colon.
3. The provider inspects the rectum, sigmoid colon, and possibly part of the descending colon.
4. One or more submucosal injections are performed using a needle-tipped catheter inserted through the scope.
5. The injections may involve various substances such as botulinum toxin, steroids, India ink, or saline.
6. After the injections, the provider removes all instruments.

4. Qualifying circumstances

CPT 45335 is performed on patients who require sigmoidoscopy with directed submucosal injection(s). The procedure is typically used to treat certain conditions or lesions in the rectum and sigmoid colon. It is important to note that CPT code 45335 should not be reported in conjunction with CPT codes 45334 and 45349 for the same lesion, or with CPT code 45330.

5. When to use CPT code 45335

CPT code 45335 should be used when a healthcare provider performs sigmoidoscopy with directed submucosal injection(s) using a flexible endoscope. It is important to ensure that the procedure meets the specific requirements outlined in the code description. CPT code 45335 should not be reported in conjunction with CPT codes 45334 and 45349 for the same lesion, or with CPT code 45330.

6. Documentation requirements

To support a claim for CPT code 45335, the healthcare provider must document the following information:

• Patient’s diagnosis or reason for the procedure
• Details of the procedure, including the use of a flexible endoscope and submucosal injections
• Substances used for the injections, if applicable
• Date and duration of the procedure
• Any additional relevant information or findings

7. Billing guidelines

When billing for CPT code 45335, it is important to follow the specific guidelines and requirements. Ensure that the procedure meets the criteria outlined in the code description. Additionally, do not report CPT code 45335 in conjunction with CPT codes 45334 and 45349 for the same lesion, or with CPT code 45330. It is recommended to check payer and coding guidelines for any specific requirements or considerations.

8. Historical information

CPT code 45335 was added to the Current Procedural Terminology system on January 1, 2003. There have been no updates to the code since its addition.

9. Examples

1. A gastroenterologist performing sigmoidoscopy with directed submucosal injection of botulinum toxin to treat a rectal spasm.
2. A colorectal surgeon using sigmoidoscopy with directed submucosal injection of steroids to treat inflammation in the sigmoid colon.
3. An oncologist performing sigmoidoscopy with directed submucosal injection of India ink to mark a lesion for surgical removal.
4. A gastroenterologist using sigmoidoscopy with directed submucosal injection of saline to lift a polyp for easier removal.
5. A general surgeon performing sigmoidoscopy with directed submucosal injection of steroids to treat ulcerative colitis.
6. A gastroenterologist using sigmoidoscopy with directed submucosal injection of botulinum toxin to treat an anal fissure.
7. A colorectal surgeon performing sigmoidoscopy with directed submucosal injection of saline to lift a lesion for biopsy.
8. An oncologist using sigmoidoscopy with directed submucosal injection of India ink to mark the margins of a tumor for surgical resection.
9. A gastroenterologist performing sigmoidoscopy with directed submucosal injection of steroids to treat radiation proctitis.
10. A general surgeon using sigmoidoscopy with directed submucosal injection of saline to lift a polyp for electrocautery removal.