(2023) CPT Code 45380 | Description, Guidelines, Reimbursement, Modifiers & Examples

CPT code 45380 is used for billing services when a flexible colonoscopy is performed by taking single or multiple biopsies. The colonoscope is introduced into the patient’s body via the anus. It traverses through the whole colon to the cecum to visualize the lumen of the colon and rectum. The colonoscopy will be removed after the extraction of tissue samples.

Description Of CPT Code 45380

CPT 45380 also included specimen collection or testing like biopsies. Colonoscopy CPT code 45380 is usually performed to detect intestinal signs and symptoms.

These include rectal bleeding, Chronic constipation, other intestinal disorders, abdominal pain, and chronic diarrhea, and to identify polyps or remove polyps in the large intestine.

Colonoscopy is also performed for screening purposes, while patients above 50 have higher chances of colon cancer. Therefore, physicians normally recommend Colon screening every ten years or earlier to detect colon cancer.

Colonoscopy will be reported with CPT 45380 when performed flexibly, with biopsy single or multiple.

Reimbursement

A maximum of 1 CPT 45380 can be billed on the same service date, while two units can be billed when documentation supports the medical necessity of CPT code 45380.

When performed in the facility, the cost and RUVS of the 45380 CPT code will be $202.79 and 6.26200, respectively. At the same time, non-facility will be $519.23 and 15.00400, respectively.

Modifiers

Modifier PT will be appended with CPT 45380 when the Screening colonoscopy is converted into a diagnostic colonoscopy due to incidental findings such as colon polyps for Medicare insurance.

In contrast, modifier 33 will be applicable for commercial insurance. For example, the patient visited the physician for a routine colonoscopy screening, revealing colon polyps.

The physician changed the screening colonoscopy into diagnostic for polyp removal or biopsy. It would be codes like 45380-PT, Z12.11, and K63.5.

Modifier 52 is applicable with the 45380 CPT code when an incomplete colonoscopy is performed with complete colonoscopy preparation.

In contrast, modifier 53 will be attached if the colonoscopy is terminated and the physician plans to redo the colonoscopy in the future.

Modifier 59 applies to CPT code 45380 if any other procedure is done in combination with these services that are generally not billed together on the same service date.

If so, modifier 59 will be appropriate, while modifier 51 is applicable when the other procedure is not a component of CPT code 45380.

Modifier 23 is applicable with CPT code 45380 if general or local anesthesia is given to patients who are usually not required for the procedure. 

Modifier 76 will be attached to CPT code 45380 if service is repeated by the same physician on the same date of service, while modifier 77 if the procedure has been done by a different physician on the same date of service, respectively.

Modifier 78 will be appended with CPT code 45380 if the procedure is repeated with the exact condition of the global period. In contrast, modifier 79 is applicable when the procedure is reported for an unrelated condition.

Billing Guidelines

CPT 45380 includes bleeding control if bleeding occurs due to the endoscopic procedure during the same operative session.

CPT code 45380 cannot be billed together on the same date service in conjunction with CPT codes 45378 (diagnostic colonoscopy) and 45390 (colonoscopy with endoscopic mucosal resection same lesion).

CPT 45380 includes the entire colon if it examines from the rectum to the cecum or terminal ilium when performed.

Modifier 73 is appropriate to attach with CPT 45380 when the Colonoscopy procedure is terminated before the administration of anesthesia, and insurance will pay 50% for this service.

In comparison, modifier 74 will be appended with CPT 45380 if the procedure is terminated after anesthesia, and insurance will pay 100% for this service.

If Colonoscopy procedure 45380 is not completed due to any circumstances and the physician plans to repeat the colonoscopy, modifier 53 is appropriate to attach with CPT 45380.

While modifier 52 only applies if the physician terminates the procedure and cannot perform it again due to the patient’s current condition or any other reason, it is appropriate to bill CPT code 45380 with modifier 52.

CPT codes 45379-45393, 45388, and 45398 (Colonoscopy flexible) are not allowed to bill together on the same date of service in conjunction with CPT 45380, and the modifier is also not allowed according to NCCI (National Correct Coding Initiative).

CPT 45380 (Colonoscopy) is mostly a more complex procedure; it is not separately reportable. It is only reportable when performed alone or for an unrelated condition with appropriate modifier 59 or XP, XE, XU, XS.

If computed tomographic Colonography (CPT codes 74261-74263) is performed, these codes are separately reportable with CPT code 45380.

Surgical endoscopy always includes diagnostic colonoscopy, and it is not separately reportable.

Medicare or other insurances cover HCPCS level II codes G0105 or G0121 instead of CPT code 45380.

If a diagnostic colonoscopy is performed and the physician cannot reach the splenic flexure, it will be reported with CPT code 45330 instead of CPT 45380.

While the physician reaches the splenic flexure but not to the cecum, it would be appropriate to bill CPT 45380 with modifier 53.

If the cecum is also reviewed and reaches that point, CPT 45380 can be reported without any modifier. 

Therapeutic Colonoscopy procedures are reported with different CPT codes (45331 – 45347, 45379 – 45398) instead of CPT code 45380.

If a colonic decompression procedure is performed, it would be reported with the 45393 CPT code instead of 45380. CPT 45380 is not allowed to bill together with CPT code 45380.

Documentation should support the medical necessity and reflect the patient’s condition to perform this service.

Can You Bill CPT Codes 45380 And 45381 Together?

CPT 45380 and 45381 are allowed to be billed together on the same service date when any injection or substance is administrated to the patient without any NCCI conflict. Therefore, the modifier is also not required. 

Examples

The following are examples of when CPT code 45380 can be billed:

Example 1

A 20-year-old male presents to the office with a severe headache, nausea, approximately eight episodes of non-bloody vomiting, approximately three episodes of non-bloody diarrhea, and severe body aches since this morning.

He also had a family history of colon cancer. He denies fever, chills, urinary complaints, chest pain, cough, back pain, and recent travel. Patient conditions were not better by giving medications, and pain became worse in the upper abdominal region.

He denies any weight changes and no jaundice. The patient was unable to eat or drink anything. The physician decided to do a Colonoscopy to diagnose the problem better.

The physician saw polyps during the colonoscopy procedure, and three biopsy samples were taken and sent to labs for laboratory testing. 

Example 2 

A 51-year-old male who denies any past medical history presents to the ED (Emergency Dept) with lower abdominal x 5 days on and off, mostly constant now, burning in nature, 9 out of 10, and worse on exertion.

He is unable to take any food. He denies shortness of breath, diaphoresis, nausea, vomiting, cough, hemoptysis, palpitations, leg pain, or swelling.

No excessive belching, flatus, diarrhea, constipation, fever, or chills exist. Physical exams revealed that pain is related to the colon despite heart-related and differential dx being Colitis.

Diagnostic studies like CT and MRI of the abdomen and pelvis revealed that the large intestine is severely inflamed. The doctor consulted with a Gerontologist, and he suggested doing a Colonoscopy to treat the inflamed large intestine.

The patient placed an appointment with a gastroenterologist for a colonoscopy. A colonoscopy revealed abnormal findings during the procedure, and biopsy samples were taken.

Example 3 

A 47-year-old female presented to the emergency department with generalized abdominal pain, chronic constipation, nausea, vomiting, and diarrhea since this morning.

The patient states that she woke up this morning with symptoms and has had many episodes of bilious vomiting and bloody, watery diarrhea since this morning.

She states that she has never faced any problem previously. She denies numbness, tingling, headache, and itching. The physician performed diagnostic studies to reveal the problem and ordered IV fluids, Pepcid, Toradol, and Zofran to treat diarrhea and pain.

The pain was getting worse after the medications. Physical exam revealed that differential dx are Appendicitis, gastritis, Colitis, and diverticulitis.

After consulting with a GI specialist, the physician decided to do a Colonoscopy with multiple biopsies. CPT and MRI of the abdomen show abnormal findings. 

Example 4

The patient presented to the gastroenterologist with abnormal findings of CT and MRI of the abdominal and pelvic region, and masses were seen in the colon region.

The physician suggested a colonoscopy with biopsies for the patient.