How To Use CPT Code 45346

CPT 45346 describes the procedure of sigmoidoscopy with ablation of tumor(s), polyp(s), or other lesion(s) in the sigmoid colon. 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 45346?

CPT 45346 can be used to describe the procedure of sigmoidoscopy with ablation of tumor(s), polyp(s), or other lesion(s) in the sigmoid colon. This code is used when the provider uses a flexible sigmoidoscope to examine the sigmoid colon and performs ablation of any present polyps, tumors, or lesions. The procedure may also include predilation and postdilation, as well as guide wire passage if necessary.

2. Official Description

The official description of CPT code 45346 is: ‘Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed).’ It is important to note that CPT code 45346 should not be reported in conjunction with CPT code 45330 or CPT code 45340 for the same lesion.

3. Procedure

1. The provider begins by appropriately prepping and anesthetizing the patient.
2. She then inserts a flexible sigmoidoscope through the anus and advances it upward to examine the rectum and sigmoid colon.
3. During the examination, the provider identifies any polyps, tumors, or other lesions present in the sigmoid colon.
4. She places the sigmoidoscope at the site of the lesion and performs ablation, which involves the removal or destruction of the tissue or lesion.
5. If necessary, the provider may perform predilation and/or postdilation at the site before or after the ablation.
6. In some cases, the provider may use a guide wire to assist in positioning the sigmoidoscope and other instruments.
7. Once the ablation and any additional procedures are completed, the provider removes the sigmoidoscope from the patient.

4. Qualifying circumstances

CPT 45346 is typically performed on patients who have polyps, tumors, or other lesions in the sigmoid colon that require ablation. The procedure is performed by a provider who is skilled in using a flexible sigmoidoscope and performing ablation. It is important to note that CPT code 45346 should not be reported in conjunction with CPT code 45330 or CPT code 45340 for the same lesion.

5. When to use CPT code 45346

CPT code 45346 should be used when a provider performs sigmoidoscopy with ablation of tumor(s), polyp(s), or other lesion(s) in the sigmoid colon. It is important to ensure that the procedure meets the specific criteria outlined in the code description, including the use of a flexible sigmoidoscope, ablation of the identified lesions, and any necessary predilation, postdilation, or guide wire passage.

6. Documentation requirements

To support a claim for CPT code 45346, the provider must document the following information:

• Patient’s diagnosis indicating the presence of polyps, tumors, or other lesions in the sigmoid colon
• Description of the procedure performed, including the use of a flexible sigmoidoscope, ablation of the identified lesions, and any additional procedures such as predilation, postdilation, or guide wire passage
• Date of the procedure
• Start and end time of the procedure
• Any complications or adverse events that occurred during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 45346, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The provider should not report CPT code 45346 in conjunction with CPT code 45330 or CPT code 45340 for the same lesion. It is also important to follow any additional guidelines provided by the payer or coding guidelines. If the provider uses a snare technique instead of ablation, CPT code 45338 should be used instead of CPT code 45346.

8. Historical information

CPT code 45346 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Examples

1. A provider performs sigmoidoscopy with ablation of a polyp in the sigmoid colon.
2. During a sigmoidoscopy procedure, the provider identifies and ablates multiple tumors in the sigmoid colon.
3. A patient undergoes sigmoidoscopy with ablation of a lesion in the sigmoid colon.
4. During a sigmoidoscopy procedure, the provider performs ablation of a polyp and predilation at the site.
5. A provider performs sigmoidoscopy with ablation of a tumor and postdilation at the site in the sigmoid colon.
6. During a sigmoidoscopy procedure, the provider identifies and ablates multiple lesions in the sigmoid colon using a guide wire for assistance.
7. A patient undergoes sigmoidoscopy with ablation of a polyp and postdilation at the site in the sigmoid colon.
8. During a sigmoidoscopy procedure, the provider performs ablation of a tumor and predilation at the site using a guide wire.