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CPT Code 45378 | Colonoscopy, Flexible; Diagnostic Including Specimen Collection

CPT code 45378 can be billed for colonoscopy with a flexible tube for diagnostic purposes and specimen collection.

1. What Is CPT Code 45378?

CPT 45378 can be used for flexible colonoscopy. A provider uses a colonoscope with a flexible tube and inserts it into the patient to examine the rectum and colon.

They look for abnormal tissue or mucosa and take examples with a brush passed through the scope. They can also rinse the examined area with warm saline, which is also inserted through the colonoscope.

For further analysis, the collected specimens are diagnosed in a laboratory.

2. Description

The CPT book describes CPT 45378 as: “Colonoscopy, flexible; diagnostic, including a collection of specimen(s) by brushing or washing, when performed (separate procedure).”

3. Procedure

When the patient is appropriately prepped and anesthetized, the provider inserts a colonoscope through the anus and advances it beyond the colon’s transverse and descending segments.

The provider then inspects the lumen of the colon and rectum using the scope. He may collect specimens from the colon’s lumen by brushing or washing the surface.

Brushing is when the provider uses a soft brush to wipe the colon tissue gently or scrape a lesion. 

In washing, the provider instills warm saline and aspirates the fluid through the scope.

He sends any specimens he collects by either method to the laboratory for analysis. Once the provider completes the procedure, he withdraws the scope.

4. How To Use CPT 45378?

Because CPT code 45378 is a separate procedure, you should report the service only when not integral to the performance of a more extensive procedure simultaneously.

Append modifier 59 when the provider performs an unrelated procedure with CPT 45378.

5. Example

A 20-year-old male has had the following symptoms since the morning; a severe headache, nausea, approximately eight episodes of non-bloody vomiting, and around three episodes of non-bloody diarrhea with severe body aches. He also had a family history of colon cancer.

His condition did not improve with medications, the pain worsened in the upper abdominal region, and the patient could not eat or drink anything.

The physician decided to do a colonoscopy with a flexible tube to diagnose the patient.

This case can be billed with CPT code 45378.

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