How To Use CPT Code 45342

CPT 45342 describes the procedure of sigmoidoscopy with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s). 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 45342?

CPT 45342 is a code used to describe a specific procedure called sigmoidoscopy with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s). This procedure involves the use of a sigmoidoscope, a flexible tube with a camera, to examine the anus, rectum, and sigmoid colon. The provider also uses ultrasound guidance to perform a fine needle aspiration or biopsy of abnormal tissue.

2. Official Description

The official description of CPT code 45342 is: ‘Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s).’ It is important to note that this code should not be reported in conjunction with other specific codes, such as 45330, 45341, 76872, 76942, or 76975. Additionally, CPT 45342 should not be reported more than once per session.

3. Procedure

1. During the procedure, the provider inserts a sigmoidoscope through the anus and advances it to the anal canal, rectum, and sigmoid colon.
2. Using the scope, the provider examines the colon for the presence of abnormal tissue or lesions.
3. An ultrasound probe is then introduced through the channel in the scope to perform an ultrasound examination of the colon, allowing the provider to diagnose any pathology.
4. Under ultrasound guidance, the provider inserts a fine gauge needle through the scope and aspirates a fluid sample consisting of cells from the area of the lesion or tumor.
5. The provider may also take several samples of abnormal tissue for biopsy.
6. Once the procedure is complete, the provider removes the ultrasound probe and the scope.

4. Qualifying circumstances

CPT 45342 is typically performed on patients who require further evaluation of the anus, rectum, and sigmoid colon. The procedure is used to diagnose and obtain samples of abnormal tissue or lesions for further analysis. It is important to note that CPT 45342 should not be reported in conjunction with other specific codes, as mentioned in the official description.

5. When to use CPT code 45342

CPT code 45342 should be used when a provider performs a sigmoidoscopy with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s). This code should not be reported with other specific codes, as mentioned in the official description.

6. Documentation requirements

To support a claim for CPT 45342, the provider must document the following information:

• Patient’s medical history and reason for the procedure
• Details of the sigmoidoscopy procedure, including the use of ultrasound guidance
• Findings from the examination, including any abnormalities or lesions
• Description of the fine needle aspiration or biopsy procedure
• Results of the aspiration or biopsy, if available
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 45342, ensure that the procedure meets the criteria described in the official description. It is important to note that CPT 45342 should not be reported in conjunction with other specific codes, as mentioned earlier. Follow the appropriate coding guidelines and modifiers when submitting the claim.

8. Historical information

CPT 45342 was added to the Current Procedural Terminology system on January 1, 2001. There have been no updates or changes to the code since its addition.

9. Examples

1. A gastroenterologist performing a sigmoidoscopy with transendoscopic ultrasound guided intramural fine needle aspiration to obtain a tissue sample for further analysis.
2. A colorectal surgeon using a sigmoidoscope with transendoscopic ultrasound guidance to perform a transmural fine needle biopsy of a suspicious lesion in the sigmoid colon.
3. An oncologist performing a sigmoidoscopy with transendoscopic ultrasound guided intramural fine needle aspiration to diagnose the presence of a tumor in the rectum.
4. A gastroenterologist performing a sigmoidoscopy with transendoscopic ultrasound guided transmural fine needle biopsy to obtain multiple tissue samples for biopsy from different areas of the sigmoid colon.
5. A radiologist using a sigmoidoscope with transendoscopic ultrasound guidance to perform a transmural fine needle aspiration of a suspected tumor in the anal canal.
6. A general surgeon performing a sigmoidoscopy with transendoscopic ultrasound guided intramural fine needle biopsy to obtain a tissue sample from a lesion in the rectum.
7. An interventional radiologist using a sigmoidoscope with transendoscopic ultrasound guidance to perform a transmural fine needle aspiration of a tumor in the sigmoid colon.
8. A gastroenterologist performing a sigmoidoscopy with transendoscopic ultrasound guided intramural fine needle biopsy to obtain a tissue sample from a suspicious lesion in the anal canal.
9. A colorectal surgeon using a sigmoidoscope with transendoscopic ultrasound guidance to perform a transmural fine needle aspiration of a tumor in the rectum.
10. An oncologist performing a sigmoidoscopy with transendoscopic ultrasound guided intramural fine needle biopsy to obtain multiple tissue samples for biopsy from different areas of the anal canal.