How To Use CPT Code 45341

CPT 45341 describes the procedure of sigmoidoscopy with endoscopic ultrasound examination. 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 45341?

CPT 45341 is used to describe the procedure of sigmoidoscopy with endoscopic ultrasound examination. This involves the use of a sigmoidoscope, a flexible tube with a camera, to examine the anus, rectum, and sigmoid colon. The provider also introduces an ultrasound probe through the scope to perform an ultrasound examination of the colon.

2. Official Description

The official description of CPT code 45341 is: ‘Sigmoidoscopy, flexible; with endoscopic ultrasound examination.’

3. Procedure

1. The provider inserts a sigmoidoscope through the anus and advances it to the anal canal, rectum, and sigmoid colon.
2. He examines a portion of the descending colon up to the splenic flexure, checking for the presence of abnormal tissue.
3. The provider then introduces an ultrasound probe through the channel in the scope and performs an ultrasound examination of the colon to diagnose any pathology.
4. Once the procedure is complete, the provider removes the ultrasound probe and the scope.

4. Qualifying circumstances

CPT 45341 is performed when there is a need to examine the inner part of the anus, rectum, and sigmoid colon using a sigmoidoscope and perform an ultrasound examination of the colon. It is important to note that CPT 45341 should not be reported in conjunction with CPT codes 45330, 45342, 76872, or 76975. Additionally, CPT 45341 should not be reported more than once per session.

5. When to use CPT code 45341

CPT code 45341 should be used when a sigmoidoscopy with endoscopic ultrasound examination is performed. It is important to ensure that the procedure is not being reported with other specific codes and that it is not being reported more than once per session.

6. Documentation requirements

To support a claim for CPT 45341, the provider must document the following information:

• Reason for performing the sigmoidoscopy with endoscopic ultrasound examination
• Details of the procedure, including the use of a sigmoidoscope and ultrasound probe
• Date and duration of the procedure
• Findings from the examination, including any abnormalities
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 45341, ensure that the procedure meets the criteria for this specific code. It is important to follow the guidelines and not report CPT 45341 in conjunction with other specific codes. Additionally, CPT 45341 should not be reported more than once per session.

8. Historical information

CPT 45341 was added to the Current Procedural Terminology system on January 1, 2001. There have been no updates to the code since its addition.

9. Examples

1. A gastroenterologist performing a sigmoidoscopy with endoscopic ultrasound examination to diagnose a suspected tumor in the sigmoid colon.
2. A colorectal surgeon using CPT 45341 to perform a sigmoidoscopy with endoscopic ultrasound examination to evaluate a patient with rectal bleeding.
3. An oncologist performing a sigmoidoscopy with endoscopic ultrasound examination to stage a known colorectal cancer.
4. A gastroenterologist using CPT 45341 to perform a sigmoidoscopy with endoscopic ultrasound examination to assess the extent of inflammation in a patient with ulcerative colitis.
5. A radiologist performing a sigmoidoscopy with endoscopic ultrasound examination to guide a biopsy of a suspicious lesion in the rectum.
6. A gastroenterologist using CPT 45341 to perform a sigmoidoscopy with endoscopic ultrasound examination to evaluate a patient with unexplained abdominal pain.
7. A general surgeon performing a sigmoidoscopy with endoscopic ultrasound examination to assess the response to treatment in a patient with rectal cancer.
8. An interventional radiologist using CPT 45341 to perform a sigmoidoscopy with endoscopic ultrasound examination to guide the placement of a drainage catheter in a patient with a perirectal abscess.
9. A gastroenterologist performing a sigmoidoscopy with endoscopic ultrasound examination to evaluate a patient with a history of polyps in the sigmoid colon.
10. A colorectal surgeon using CPT 45341 to perform a sigmoidoscopy with endoscopic ultrasound examination to assess the response to treatment in a patient with Crohn’s disease.