How To Use CPT Code 45380

CPT 45380 refers to a flexible colonoscopy procedure with biopsy, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 45380?

CPT 45380 is a medical code used to describe a flexible colonoscopy procedure that involves the examination of the rectum and colon using a colonoscope, with the purpose of taking one or more biopsies of suspicious tissue areas. This code is used by medical coders and billers to accurately document and bill for this specific procedure.

2. 45380 CPT code description

The official description of CPT code 45380 is: “Colonoscopy, flexible; with biopsy, single or multiple.”

3. Procedure

  1. The patient is prepped and anesthetized.
  2. The provider inserts a colonoscope through the anus and advances it to the descending segment of the colon.
  3. The provider inspects the lumen of the colon and rectum using the scope, checking for the presence of abnormal tissue.
  4. One or more samples of suspicious tissue are taken using biopsy forceps.
  5. All instruments are removed, and the colonoscope is withdrawn.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 45380 services are those experiencing symptoms such as diarrhea, constipation, rectal bleeding, or abdominal pain, which may indicate the presence of abnormal tissue in the colon or rectum. The flexible colonoscopy with biopsy procedure is performed to diagnose and determine the cause of these symptoms.

5. When to use CPT code 45380

It is appropriate to bill the 45380 CPT code when a provider performs a flexible colonoscopy with biopsy, single or multiple, to examine the rectum and colon for abnormal tissue and take samples for laboratory analysis. This code should be used regardless of the number of biopsies taken during the procedure.

6. Documentation requirements

To support a claim for CPT 45380, the following information needs to be documented:

  • Patient’s medical history and presenting symptoms
  • Physical examination findings
  • Indication for the colonoscopy procedure
  • Details of the colonoscopy procedure, including the scope used, the extent of the examination, and any findings
  • Number and location of biopsies taken
  • Pathology report of the biopsied tissue
  • Follow-up plan and recommendations

7. Billing guidelines

When billing for CPT code 45380, it is important to follow the appropriate guidelines and rules. Report 45380 only once, regardless of the number of biopsies taken during the procedure. If the procedure is unusually extensive or time-consuming, modifier 22 (Increased procedural services) can be appended, but a well-documented and convincing argument must be provided to the payer for additional reimbursement. Do not report 45380 in conjunction with 45390 or 45378 for the same lesion.

8. Historical information

CPT 45380 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2015, with the previous descriptor being “Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple.”

9. Similar codes to CPT 45380

Five similar codes to CPT 45380 and how they differentiate are:

  • CPT 45378: A basic diagnostic colonoscopy without biopsy or other interventions.
  • CPT 45381: A colonoscopy with submucosal injection, which involves injecting a solution beneath the mucosal layer to lift and separate it from the underlying tissue.
  • CPT 45382: A colonoscopy with control of bleeding, such as through cauterization or injection of a hemostatic agent.
  • CPT 45383: A colonoscopy with ablation of tumors or polyps using techniques like laser or argon plasma coagulation.
  • CPT 45384: A colonoscopy with removal of tumors or polyps using a snare technique.

10. Examples

  1. A patient presents with rectal bleeding and a history of polyps. CPT 45380 is performed to examine the colon and take biopsies of suspicious tissue.
  2. A patient with chronic diarrhea undergoes CPT 45380 to investigate the cause and obtain biopsies for analysis.
  3. A patient with a family history of colon cancer has CPT 45380 performed as a screening measure, with biopsies taken from suspicious areas.
  4. A patient with unexplained abdominal pain undergoes CPT 45380 to rule out inflammatory bowel disease, with biopsies taken for histopathological examination.
  5. A patient with iron deficiency anemia and a positive fecal occult blood test has CPT 45380 performed to investigate potential sources of bleeding in the colon.
  6. A patient with a history of ulcerative colitis undergoes CPT 45380 for surveillance and assessment of disease activity, with biopsies taken for histological evaluation.
  7. A patient with persistent constipation and a history of diverticulosis has CPT 45380 performed to evaluate the colon and obtain biopsies of any suspicious areas.
  8. A patient with a change in bowel habits and weight loss undergoes CPT 45380 to investigate the cause and obtain biopsies for analysis.
  9. A patient with a history of Lynch syndrome has CPT 45380 performed as part of a regular surveillance program, with biopsies taken from any suspicious areas.
  10. A patient with a positive result on a fecal immunochemical test undergoes CPT 45380 to examine the colon and take biopsies of any suspicious tissue.

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