How To Use CPT Code 45379

CPT 45379 describes the procedure of colonoscopy with the removal of foreign bodies. 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 45379?

CPT 45379 is used to describe the procedure of colonoscopy with the removal of foreign bodies. It involves the examination of the colon and rectum using a colonoscope, a flexible tubular instrument with a light source and camera. The provider inserts the colonoscope through the anus and advances it to the descending colon to identify and remove foreign bodies that could obstruct or damage the colon.

2. Official Description

The official description of CPT code 45379 is: ‘Colonoscopy, flexible; with removal of foreign body(s).’ It is important to note that CPT code 45379 should not be reported in conjunction with CPT code 45378. If fluoroscopic guidance is performed during the procedure, CPT code 76000 should be used.

3. Procedure

1. The provider prepares the patient for the procedure, ensuring appropriate prepping and anesthesia.
2. The provider inserts a colonoscope through the anus and advances it to the descending colon.
3. Using the colonoscope, the provider inspects the lumen of the colon and rectum to identify the presence of foreign bodies.
4. If foreign bodies are found, the provider introduces forceps through a channel in the colonoscope and removes them.
5. Once the foreign bodies are removed, the provider withdraws the colonoscope and removes all instruments.

4. Qualifying circumstances

CPT 45379 is performed when there is a need to remove foreign bodies from the colon. Foreign bodies can include objects that have been swallowed and could potentially cause harm or obstruction in the gastrointestinal tract. The procedure is typically performed on patients who have ingested or inserted foreign bodies into the lower gastrointestinal tract. It is important to note that CPT code 45379 should not be reported in conjunction with CPT code 45378.

5. When to use CPT code 45379

CPT code 45379 should be used when a colonoscopy is performed specifically for the removal of foreign bodies from the colon. It is important to ensure that the procedure meets the criteria outlined in the official description of the code. CPT code 45379 should not be used in conjunction with CPT code 45378, as they represent different procedures.

6. Documentation requirements

To support a claim for CPT code 45379, the provider must document the following information:

• Reason for the procedure and the presence of foreign bodies in the colon
• Details of the colonoscopy procedure, including the use of a colonoscope and any additional instruments
• Date and duration of the procedure
• Specific foreign bodies removed, if applicable
• Any complications or additional findings during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 45379, it is important to ensure that the procedure meets the criteria outlined in the official description. CPT code 45379 should not be reported in conjunction with CPT code 45378. If fluoroscopic guidance is performed during the procedure, CPT code 76000 should be used. It is important to follow the specific guidelines provided by the payer and to accurately report the services provided.

8. Historical information

CPT code 45379 was added to the Current Procedural Terminology system on January 1, 1990. There was a code change on January 1, 2015, which resulted in the addition of a more specific code for colonoscopy with the removal of foreign bodies proximal to the splenic flexure.

9. Examples

1. A provider performs a colonoscopy and removes a swallowed coin from the descending colon.
2. During a colonoscopy, a provider identifies and removes a small bone fragment that was causing discomfort in the rectum.
3. A patient presents with abdominal pain, and a colonoscopy reveals the presence of a foreign object that the provider removes.
4. During a routine colonoscopy, the provider discovers and removes a piece of metal that the patient had accidentally ingested.
5. A colonoscopy is performed on a patient who had inserted a foreign object into the rectum, and the provider successfully removes it.
6. A provider performs a colonoscopy and removes a plastic toy that a child had swallowed.
7. During a colonoscopy, the provider identifies and removes a piece of glass that was causing bleeding in the colon.
8. A patient presents with symptoms of bowel obstruction, and a colonoscopy reveals the presence of a foreign body that the provider removes.
9. During a colonoscopy, the provider discovers and removes a sharp object that the patient had accidentally ingested.
10. A colonoscopy is performed on a patient who had inserted a foreign object into the rectum, and the provider successfully removes it.