How To Use CPT Code 45381

CPT 45381 describes the procedure of flexible colonoscopy with directed submucosal injection(s) of any substance. 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 45381?

CPT 45381 can be used to describe the procedure of flexible colonoscopy with directed submucosal injection(s) of any substance. This code is used when a healthcare provider inserts a flexible endoscope into the anus and navigates it through the entire colon. During the procedure, the provider performs one or more injections into the submucosa, which is the tissue below the mucous membrane.

2. Official Description

The official description of CPT code 45381 is: ‘Colonoscopy, flexible; with directed submucosal injection(s), any substance.’ It is important to note that this code should not be reported in conjunction with codes 45382 and 45390 for the same lesion, or with code 45378.

3. Procedure

1. The healthcare provider ensures that the patient is appropriately prepped and anesthetized.
2. The provider inserts a flexible endoscope into the anus and maneuvers it through the entire colon.
3. The provider inspects the colon, including the rectum, cecum, and possibly the terminal ileum or the part of the small intestine by an anastomosis.
4. The provider performs one or more submucosal injections of any substance, typically using a needle-tipped catheter inserted through the scope.
5. The substances used for injection can vary and may include botulinum toxin, steroids, India ink, or saline.
6. After the injections are completed, the provider removes all instruments.

4. Qualifying circumstances

CPT 45381 is performed on patients who require a flexible colonoscopy with directed submucosal injection(s) for diagnostic or therapeutic purposes. The procedure is typically performed by a healthcare provider who is trained in performing colonoscopies and has the necessary equipment and expertise. The injections into the submucosa may involve various substances, depending on the specific needs of the patient.

5. When to use CPT code 45381

CPT code 45381 should be used when a healthcare provider performs a flexible colonoscopy and performs one or more directed submucosal injections of any substance. This code is appropriate for both diagnostic and therapeutic procedures. It is important to note that CPT code 45381 should not be reported in conjunction with codes 45382 and 45390 for the same lesion, or with code 45378.

6. Documentation requirements

To support a claim for CPT code 45381, the healthcare provider must document the following information:

• Indication for the procedure
• Details of the flexible colonoscopy, including the extent of the examination and any findings
• Description of the directed submucosal injection(s), including the substance used
• Date and duration of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 45381, ensure that the procedure meets the criteria outlined in the official description. It is important to follow payer and coding guidelines to ensure accurate and appropriate billing. Additionally, do not report CPT code 45381 in conjunction with codes 45382 and 45390 for the same lesion, or with code 45378.

8. Historical information

CPT code 45381 was added to the Current Procedural Terminology system on January 1, 2003. On January 1, 2015, the code description was changed to ‘Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.’

9. Examples

1. A gastroenterologist performs a flexible colonoscopy with directed submucosal injection of botulinum toxin to treat a patient with a rectal sphincter disorder.
2. A surgeon performs a flexible colonoscopy with directed submucosal injection of India ink to mark a lesion for surgical removal in a patient with suspected colon cancer.
3. A gastroenterologist performs a flexible colonoscopy with directed submucosal injection of steroids to treat inflammation in a patient with ulcerative colitis.
4. A gastroenterologist performs a flexible colonoscopy with directed submucosal injection of saline to lift a polyp for easier removal in a patient with a history of colon polyps.
5. A gastroenterologist performs a flexible colonoscopy with directed submucosal injection of a dye to visualize blood vessels in a patient with suspected gastrointestinal bleeding.
6. A surgeon performs a flexible colonoscopy with directed submucosal injection of saline to lift a lesion for easier removal in a patient with a large colon polyp.
7. A gastroenterologist performs a flexible colonoscopy with directed submucosal injection of steroids to treat inflammation in a patient with Crohn’s disease.
8. A surgeon performs a flexible colonoscopy with directed submucosal injection of botulinum toxin to treat a patient with an anal fissure.
9. A gastroenterologist performs a flexible colonoscopy with directed submucosal injection of India ink to mark a lesion for surgical removal in a patient with a history of colon polyps.