Report CPT 45390 if a provider performed an endoscopic examination of the lower gastrointestinal (GI) tract with a flexible fiberoptic endoscope.
What Is CPT Code 45380?
CPT code 45380 is used to report the endoscopic examination of the lower gastrointestinal (GI) tract using a flexible fiberoptic endoscope.
This procedure, also known as flexible sigmoidoscopy, involves the insertion of a flexible endoscope through the rectum and into the lower part of the colon (sigmoid colon and rectum) to visualize the lining of these structures.
CP 45380 is used to evaluate symptoms such as rectal bleeding, abdominal pain, or changes in bowel habits or to screen for conditions such as colon cancer or inflammatory bowel disease.
The procedure may also involve the collection of tissue samples (biopsy) for laboratory analysis or removing small growths (polyps) that may be present in the colon.
The CPT book describes CPT 45380 as: “Colonoscopy, flexible; with biopsy, single or multiple.”
When the patient is appropriately prepped and anesthetized, the provider inserts a colonoscope through the anus and advances it to the descending segment of the colon.
The provider then inspects the lumen of the colon and rectum using the scope and checks for the presence of abnormal tissue. Next, he takes one or more samples of this tissue using biopsy forceps.
The provider then removes all instruments and withdraws the colonoscope.
How To Use CPT 45380?
No matter how many biopsies your provider takes, report CPT 45380 only once. If the procedure is unusually extensive or time-consuming, you could append modifier 22, Increased procedural services.
You would have to provide the payer with a well–documented and convincing argument, including a comparison of time with a standard biopsy procedure, several biopsies and sites, and evidence of substantial complications as to why you are entitled to additional reimbursement. Your claim may still be denied, however.
Do not report CPT 45380 with CPT 45390 for the same lesion.
Do not report CPT 45380 with CPT 45378.