How To Use CPT Code 45349

CPT 45349 describes the procedure of flexible sigmoidoscopy with endoscopic mucosal resection. 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 45349?

CPT 45349 is used to describe the procedure of flexible sigmoidoscopy with endoscopic mucosal resection. This code is used when a healthcare provider performs a mucosal resection using a flexible sigmoidoscope, which is a specialized instrument used to examine the rectum and sigmoid colon. During this procedure, the provider identifies any lesions in the rectum or sigmoid colon and removes them using various techniques, such as snare excision. It is important to note that CPT 45349 should not be reported in conjunction with other codes for the same lesion.

2. Official Description

The official description of CPT code 45349 is: ‘Sigmoidoscopy, flexible; with endoscopic mucosal resection.’ It is important to note that CPT 45349 should not be reported in conjunction with CPT codes 45331, 45335, 45338, or 45350 for the same lesion. Additionally, CPT 45349 should not be reported in conjunction with CPT code 45330.

3. Procedure

1. When performing a flexible sigmoidoscopy with endoscopic mucosal resection, the healthcare provider begins by appropriately prepping and anesthetizing the patient.
2. Next, the provider inserts a sigmoidoscope into the anus to examine the rectum and sigmoid colon for any lesions.
3. Once a lesion is identified, the provider may administer a submucosal injection to raise the lesion, making it easier to resect.
4. The provider then uses a snare or other means to excise the lesion.
5. In cases of deep lesions, the provider may repeat the submucosal injection.
6. After the lesion is excised, the provider ensures hemostasis and removes the sigmoidoscope.

4. Qualifying circumstances

CPT 45349 is typically performed on patients who have lesions in the rectum or sigmoid colon that require removal. The procedure is performed by a healthcare provider who is trained in performing flexible sigmoidoscopy with endoscopic mucosal resection. It is important to note that CPT 45349 should not be reported in conjunction with other codes for the same lesion.

5. When to use CPT code 45349

CPT code 45349 should be used when a healthcare provider performs a flexible sigmoidoscopy with endoscopic mucosal resection. This code should not be used in conjunction with other codes for the same lesion. It is important to review the documentation and accurately report the appropriate code based on the specific procedure performed.

6. Documentation requirements

To support a claim for CPT 45349, the healthcare provider must document the following information:

• Documentation of the patient’s prepping and anesthesia
• Identification of the lesion in the rectum or sigmoid colon
• Description of the technique used for mucosal resection
• Documentation of any submucosal injections administered
• Confirmation of hemostasis
• Removal of the sigmoidoscope

7. Billing guidelines

When billing for CPT 45349, it is important to ensure that the procedure meets the specific criteria outlined in the code description. CPT 45349 should not be reported in conjunction with other codes for the same lesion. It is important to review the documentation and accurately report the appropriate code based on the specific procedure performed.

8. Historical information

CPT 45349 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 gastroenterologist performing a flexible sigmoidoscopy with endoscopic mucosal resection to remove a lesion in the sigmoid colon.
2. A colorectal surgeon using a flexible sigmoidoscope to identify and excise a lesion in the rectum using snare technique.
3. An oncologist performing a mucosal resection using a flexible sigmoidoscope to remove a tumor in the sigmoid colon.
4. A gastroenterologist administering a submucosal injection to raise a lesion in the rectum before performing endoscopic mucosal resection.
5. A general surgeon using a snare to excise a lesion in the sigmoid colon during a flexible sigmoidoscopy.
6. A gastroenterologist ensuring hemostasis after performing endoscopic mucosal resection of a lesion in the rectum.
7. A colorectal surgeon removing a lesion in the sigmoid colon using a flexible sigmoidoscope and electrocautery.
8. An oncologist performing a flexible sigmoidoscopy with endoscopic mucosal resection to remove multiple polyps in the rectum.
9. A gastroenterologist repeating a submucosal injection in cases of deep lesions during a flexible sigmoidoscopy with endoscopic mucosal resection.
10. A general surgeon documenting the removal of the sigmoidoscope after performing endoscopic mucosal resection of a lesion in the sigmoid colon.