How To Use CPT Code 45340

CPT 45340 describes the procedure of sigmoidoscopy with transendoscopic balloon dilation. 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 45340?

CPT 45340 is used to describe the procedure of sigmoidoscopy with transendoscopic balloon dilation. This code is used when a healthcare provider examines the anus, rectum, and sigmoid colon using a sigmoidoscope, a flexible tube with a camera at its inserted end. The provider then uses a balloon catheter to dilate any strictures or abnormal narrowings in the colon.

2. Official Description

The official description of CPT code 45340 is: ‘Sigmoidoscopy, flexible; with transendoscopic balloon dilation.’

3. Procedure

1. The healthcare provider inserts a sigmoidoscope through the anus and advances it to the sigmoid colon.
2. Using the scope, the provider examines the colon and identifies any strictures or abnormal narrowings.
3. A balloon catheter is introduced through the channel in the scope and positioned at the site of the stricture.
4. The provider inflates the balloon to dilate the stricture and open the narrowed lumen of the colon.
5. Once adequate dilation is achieved, the provider deflates the balloon and repeats the procedure for any additional strictures.
6. After completing the dilation, the provider removes the sigmoidoscope and balloon catheter.

4. Qualifying circumstances

CPT 45340 is performed on patients with strictures or abnormal narrowings in the sigmoid colon. It is important to note that CPT 45340 should not be reported in conjunction with CPT codes 45330, 45346, or 45347. If fluoroscopic guidance is used during the procedure, CPT code 74360 should be reported instead. For transendoscopic balloon dilation of multiple strictures during the same session, CPT code 45340 should be reported with modifier 59 for each additional stricture dilated.

5. When to use CPT code 45340

CPT code 45340 should be used when a healthcare provider performs sigmoidoscopy with transendoscopic balloon dilation. It is important to ensure that the procedure meets the specific criteria outlined in the official description and that it is not performed in conjunction with other specific CPT codes.

6. Documentation requirements

To support a claim for CPT 45340, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the presence of strictures or abnormal narrowings in the sigmoid colon
• Details of the sigmoidoscopy procedure, including the use of a sigmoidoscope and balloon catheter
• Date of the procedure
• Specific sites of dilation and any additional strictures treated
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 45340, ensure that the procedure meets the criteria outlined in the official description. It is important to note that CPT 45340 should not be reported in conjunction with specific CPT codes (45330, 45346, or 45347). If fluoroscopic guidance is used, report CPT code 74360 instead. For transendoscopic balloon dilation of multiple strictures during the same session, use CPT code 45340 with modifier 59 for each additional stricture dilated.

8. Historical information

CPT 45340 was added to the Current Procedural Terminology system on January 1, 2003. On January 1, 2015, the code description was changed to ‘Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures.’

9. Examples

1. A gastroenterologist performs sigmoidoscopy with transendoscopic balloon dilation to treat a patient with strictures in the sigmoid colon.
2. A colorectal surgeon uses sigmoidoscopy with transendoscopic balloon dilation to dilate a stricture in the sigmoid colon of a patient with Crohn’s disease.
3. An interventional radiologist performs sigmoidoscopy with transendoscopic balloon dilation to treat a patient with strictures in the sigmoid colon caused by radiation therapy.
4. A gastroenterologist utilizes sigmoidoscopy with transendoscopic balloon dilation to dilate multiple strictures in the sigmoid colon of a patient with ulcerative colitis.
5. A general surgeon performs sigmoidoscopy with transendoscopic balloon dilation to treat a patient with strictures in the sigmoid colon caused by diverticulitis.
6. A gastroenterologist uses sigmoidoscopy with transendoscopic balloon dilation to dilate a stricture in the sigmoid colon of a patient with ischemic colitis.
7. An interventional radiologist performs sigmoidoscopy with transendoscopic balloon dilation to treat a patient with strictures in the sigmoid colon caused by an anastomotic leak.
8. A colorectal surgeon utilizes sigmoidoscopy with transendoscopic balloon dilation to dilate multiple strictures in the sigmoid colon of a patient with inflammatory bowel disease.
9. A gastroenterologist performs sigmoidoscopy with transendoscopic balloon dilation to treat a patient with strictures in the sigmoid colon caused by a foreign body obstruction.
10. An interventional radiologist uses sigmoidoscopy with transendoscopic balloon dilation to dilate a stricture in the sigmoid colon of a patient with colorectal cancer.