How To Use CPT Code 45378

CPT 45378 describes the diagnostic procedure of colonoscopy, which involves the examination of the colon and rectum using a flexible tube with a camera. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45378?

CPT 45378 is used to describe the diagnostic procedure of colonoscopy. During this procedure, a qualified healthcare provider uses a colonoscope, a flexible tube with a camera, to examine the colon and rectum. The provider may collect samples of abnormal tissue or mucosa by brushing or washing the area, which are then sent to the laboratory for analysis.

2. Official Description

The official description of CPT code 45378 is: ‘Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).’ It is important to note that this code should not be reported in conjunction with codes 45379-45393 and should not be used for colonoscopy with decompression (pathologic distention), which has its own specific code (45393).

3. Procedure

1. After appropriate patient preparation and anesthesia, the healthcare provider inserts a colonoscope through the anus and advances it beyond the transverse and descending segments of the colon.
2. The provider carefully inspects the lumen of the colon and rectum using the colonoscope, looking for any areas of abnormal mucosa or tissue.
3. If abnormalities are found, the provider may collect specimens by brushing the surface of the colon tissue or by washing the area with warm saline and aspirating the washings through the scope.
4. The collected specimens are then sent to the laboratory for diagnostic analysis.
5. Once the procedure is complete, the provider withdraws the colonoscope.

4. Qualifying circumstances

CPT 45378 is performed on patients who require a diagnostic examination of the colon and rectum. It is typically used to investigate suspected abnormalities or to screen for colorectal cancer. The procedure must be performed by a qualified healthcare provider and may involve the collection of specimens by brushing or washing the colon surface.

5. When to use CPT code 45378

CPT code 45378 should be used when a diagnostic colonoscopy is performed, including the collection of specimens by brushing or washing. It is important to note that this code should not be reported if it is integral to a larger procedure performed at the same time. Modifier 59, Distinct procedural service, should be appended if an unrelated procedure is performed alongside CPT 45378.

6. Documentation requirements

To support a claim for CPT 45378, the healthcare provider must document the following information:

• Patient’s medical history and reason for the colonoscopy
• Details of the procedure, including the use of a colonoscope and any specimen collection methods
• Date and duration of the procedure
• Findings during the examination, including any abnormalities or lesions
• Specimen collection details, if applicable
• Signature of the performing healthcare provider

7. Billing guidelines

When billing for CPT 45378, ensure that the procedure is performed as a separate service and not as part of a larger procedure. Do not report CPT 45378 in conjunction with codes 45379-45393. Modifier 59 should be appended if an unrelated procedure is performed alongside CPT 45378. It is important to follow the specific guidelines provided by the payer to ensure accurate and appropriate billing.

8. Historical information

CPT 45378 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2015, with an updated description that included the option for colon decompression and revised terminology.

9. Examples

1. A gastroenterologist performs a diagnostic colonoscopy on a patient with gastrointestinal symptoms, collecting specimens for further analysis.
2. A primary care physician refers a patient for a screening colonoscopy due to their age and family history of colorectal cancer.
3. A surgeon performs a diagnostic colonoscopy on a patient with suspected inflammatory bowel disease, collecting biopsies for histopathological examination.
4. A gastroenterologist performs a diagnostic colonoscopy on a patient with rectal bleeding, searching for the source of the bleeding.
5. A gastroenterologist performs a diagnostic colonoscopy on a patient with a positive fecal occult blood test, investigating the presence of colorectal cancer or polyps.
6. A gastroenterologist performs a diagnostic colonoscopy on a patient with chronic diarrhea, looking for potential causes such as inflammatory bowel disease or malabsorption disorders.
7. A gastroenterologist performs a diagnostic colonoscopy on a patient with unexplained weight loss and abdominal pain, searching for potential underlying conditions.
8. A gastroenterologist performs a diagnostic colonoscopy on a patient with a family history of colorectal cancer, aiming to detect any precancerous polyps or early-stage cancer.
9. A gastroenterologist performs a diagnostic colonoscopy on a patient with a history of polyps, monitoring for any recurrence or new growths.
10. A gastroenterologist performs a diagnostic colonoscopy on a patient with iron deficiency anemia, investigating potential gastrointestinal bleeding sources.