How To Use CPT Code 45338

CPT 45338 describes the procedure of sigmoidoscopy with the removal of tumor(s), polyp(s), or other lesion(s) using a snare technique. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45338?

CPT 45338 can be used to describe a specific procedure called sigmoidoscopy, which involves the examination of the anus, rectum, and sigmoid colon using a flexible sigmoidoscope. During this procedure, the provider also removes a single tumor, polyp, or other lesion using a snare technique. It is important to note that CPT 45338 should not be reported for the same lesion as CPT 45349 or in conjunction with CPT 45330.

2. Official Description

The official description of CPT code 45338 is: ‘Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.’

3. Procedure

1. When performing CPT 45338, the provider begins by appropriately prepping and anesthetizing the patient.
2. Next, the provider inserts a flexible sigmoidoscope through the anus and advances it to the anal canal, rectum, and sigmoid colon.
3. Using the scope, the provider carefully examines the internal surface of the area, looking for any abnormal tissue or lesions.
4. If a tumor, polyp, or other lesion is identified, the provider utilizes a snare technique to remove or destroy it. This involves passing a wire loop over the marked area and shaving off the abnormal tissue.
5. Once the procedure is complete, the provider withdraws the sigmoidoscope.

4. Qualifying circumstances

CPT 45338 is typically performed on patients who require the removal of a tumor, polyp, or other lesion in the anus, rectum, or sigmoid colon. The procedure is performed by a qualified healthcare provider who is skilled in using a flexible sigmoidoscope and the snare technique. It is important to note that CPT 45338 should not be reported for the same lesion as CPT 45349 or in conjunction with CPT 45330.

5. When to use CPT code 45338

CPT code 45338 should be used when a provider performs a sigmoidoscopy and removes a tumor, polyp, or other lesion using a snare technique. It is important to follow the guidelines and not report CPT 45338 for the same lesion as CPT 45349 or in conjunction with CPT 45330.

6. Documentation requirements

To support a claim for CPT 45338, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the sigmoidoscopy, including the date and start and end times
• Description of the tumor, polyp, or lesion removed
• Documentation of the snare technique used
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 45338, ensure that the procedure meets the specific criteria outlined in the code description. It is important to note that CPT 45338 should not be reported for the same lesion as CPT 45349 or in conjunction with CPT 45330. Familiarize yourself with the specific guidelines and requirements of the payer to ensure accurate and appropriate billing.

8. Historical information

CPT 45338 was added to the Current Procedural Terminology system on January 1, 1994. There have been no updates or changes to the code since its addition.

9. Examples

1. A gastroenterologist performing a sigmoidoscopy and removing a polyp using a snare technique.
2. A colorectal surgeon conducting a sigmoidoscopy and removing a tumor from the sigmoid colon using a snare technique.
3. An oncologist performing a sigmoidoscopy and removing a lesion from the rectum using a snare technique.
4. A general surgeon conducting a sigmoidoscopy and removing a polyp from the anus using a snare technique.
5. A gastroenterologist performing a sigmoidoscopy and removing a lesion from the rectum using a snare technique.
6. A colorectal surgeon conducting a sigmoidoscopy and removing a tumor from the sigmoid colon using a snare technique.
7. An oncologist performing a sigmoidoscopy and removing a polyp from the anus using a snare technique.
8. A general surgeon conducting a sigmoidoscopy and removing a lesion from the rectum using a snare technique.
9. A gastroenterologist performing a sigmoidoscopy and removing a tumor from the sigmoid colon using a snare technique.
10. An oncologist conducting a sigmoidoscopy and removing a polyp from the anus using a snare technique.