How To Use CPT Code 45380

CPT 45380 describes the examination of the rectum and colon using a flexible colonoscope, with the purpose of identifying the cause of a patient’s symptoms such as diarrhea, constipation, rectal bleeding, or abdominal pain. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45380?

CPT 45380 is used to describe the examination of the rectum and colon using a flexible colonoscope. This procedure allows the healthcare provider to visually inspect the colon and rectum to identify any abnormalities or potential causes of the patient’s symptoms. During the examination, the provider may also take one or more samples of suspicious tissue using biopsy forceps for further analysis.

2. Official Description

The official description of CPT code 45380 is: ‘Colonoscopy, flexible; with biopsy, single or multiple.’ It is important to note that CPT 45380 should not be reported in conjunction with CPT 45390 for the same lesion, or with CPT 45378.

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring appropriate prepping and anesthesia.
2. The provider inserts a flexible colonoscope through the anus and advances it to the descending segment of the colon.
3. Using the colonoscope, the provider inspects the lumen of the colon and rectum, looking for any abnormal tissue or lesions.
4. If any suspicious areas are identified, the provider uses biopsy forceps to excise one or more samples of tissue for further analysis.
5. Once the examination and biopsies are complete, the provider removes all instruments and withdraws the colonoscope.

4. Qualifying circumstances

CPT 45380 is typically performed when a patient presents with symptoms such as diarrhea, constipation, rectal bleeding, or abdominal pain, and there is a need to visually examine the colon and rectum to identify the cause of these symptoms. The procedure is performed by a healthcare provider who is trained in using a flexible colonoscope and performing biopsies. It is important to note that CPT 45380 should not be reported in conjunction with CPT 45390 for the same lesion, or with CPT 45378.

5. When to use CPT code 45380

CPT code 45380 should be used when a healthcare provider performs a colonoscopy with biopsy, either a single biopsy or multiple biopsies, using a flexible colonoscope. This code is appropriate when the provider is examining the rectum and colon to identify the cause of the patient’s symptoms and takes one or more tissue samples for further analysis.

6. Documentation requirements

To support a claim for CPT 45380, the healthcare provider must document the following information:

• Patient’s symptoms and the need for the colonoscopy
• Details of the procedure, including the use of a flexible colonoscope and any biopsies performed
• Date and duration of the procedure
• Findings during the examination, including any abnormalities or lesions
• Number of biopsies taken and their locations
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 45380, ensure that the procedure is performed by a healthcare provider who is trained in using a flexible colonoscope and performing biopsies. It is important to note that CPT 45380 should not be reported in conjunction with CPT 45390 for the same lesion, or with CPT 45378. If the procedure is unusually extensive or time-consuming, modifier 22, Increased procedural services, may be appended to the claim, along with well-documented and convincing evidence of the additional complexity and time involved.

8. Historical information

CPT 45380 was added to the Current Procedural Terminology system on January 1, 1990. On January 1, 2015, the code was changed to ‘Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple.’

9. Examples

1. A healthcare provider performs a colonoscopy with biopsy for a patient experiencing chronic abdominal pain.
2. During a colonoscopy, a healthcare provider identifies a suspicious lesion and performs a biopsy to determine if it is cancerous.
3. A patient presents with rectal bleeding, and a healthcare provider performs a colonoscopy with biopsy to identify the cause of the bleeding.
4. A healthcare provider performs a colonoscopy with multiple biopsies for a patient with a family history of colon cancer.
5. During a colonoscopy, a healthcare provider identifies and removes a polyp using a snare technique.
6. A patient with chronic diarrhea undergoes a colonoscopy with biopsy to investigate the underlying cause.
7. A healthcare provider performs a colonoscopy with biopsy for a patient with a history of inflammatory bowel disease.
8. During a colonoscopy, a healthcare provider identifies and controls bleeding using a specific method.
9. A patient with unexplained weight loss undergoes a colonoscopy with biopsy to rule out any malignancies.
10. A healthcare provider performs a colonoscopy with biopsy for a patient with a positive fecal occult blood test.