How To Use CPT Code 45382

CPT code 45382 describes a specific endoscopy procedure performed on the rectum to control bleeding using various methods. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45382?

CPT 45382 can be used to describe an endoscopy procedure performed on the rectum to control bleeding. This code is used when a healthcare provider uses a colonoscope, a flexible tubular instrument with a light source and camera, to identify the source of internal bleeding in the colon and then applies appropriate methods to control the bleeding.

2. Official Description

The official description of CPT code 45382 is: ‘Colonoscopy, flexible; with control of bleeding, any method.’ It is important to note that this code should not be reported in conjunction with codes 45381 and 45398 for the same lesion, or with code 45378.

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring appropriate prepping and anesthesia.
2. The provider inserts a colonoscope through the anus and advances it to the descending segments of the colon.
3. Using the colonoscope, the provider inspects the lumen of the colon and rectum to identify the site of internal bleeding.
4. The provider applies various methods, such as cauterization or heat sealing, to control the bleeding in the colon.
5. Once the bleeding is controlled, the provider removes all instruments and withdraws the colonoscope.

4. Qualifying circumstances

CPT 45382 is used when a patient requires an endoscopy procedure to control bleeding in the colon. This code is applicable when the healthcare provider uses a colonoscope to identify and control the source of internal bleeding. It is important to note that this code should not be reported in conjunction with codes 45381 and 45398 for the same lesion, or with code 45378.

5. When to use CPT code 45382

CPT code 45382 should be used when a healthcare provider performs an endoscopy procedure on the rectum to control bleeding using various methods. It is important to ensure that the procedure is performed on the rectum and not on other parts of the gastrointestinal tract. This code should not be reported in conjunction with codes 45381 and 45398 for the same lesion, or with code 45378.

6. Documentation requirements

To support a claim for CPT 45382, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the endoscopy procedure
• Specific methods used to control the bleeding
• Date and details of the procedure, including start and end time
• Any complications or additional interventions performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 45382, ensure that the procedure is performed on the rectum and that the appropriate methods are used to control the bleeding. It is important to follow the guidelines and not report this code in conjunction with codes 45381, 45398, or 45378. Additionally, consider any specific billing requirements from the payer or insurance company.

8. Historical information

CPT 45382 was added to the Current Procedural Terminology system on January 1, 2002. Prior to that, on January 1, 1990, a similar code was added for colonoscopy with control of bleeding, but without specifying any particular method. The code was then revised on January 1, 2015, to include the specific methods used to control bleeding.

9. Examples

1. A gastroenterologist performing an endoscopy procedure on the rectum to control bleeding using cauterization.
2. A colorectal surgeon using a colonoscope to identify and control the source of internal bleeding in the colon.
3. An interventional radiologist performing an endoscopy procedure on the rectum to control bleeding using laser therapy.
4. A general surgeon using a colonoscope to identify and control the source of internal bleeding in the rectum.
5. A gastroenterologist performing an endoscopy procedure on the rectum to control bleeding using bipolar cautery.
6. An oncologist using a colonoscope to identify and control the source of internal bleeding in the colon.
7. A proctologist performing an endoscopy procedure on the rectum to control bleeding using injection therapy.
8. A gastroenterologist using a colonoscope to identify and control the source of internal bleeding in the rectum.
9. An interventional radiologist performing an endoscopy procedure on the rectum to control bleeding using unipolar cautery.
10. A general surgeon using a colonoscope to identify and control the source of internal bleeding in the colon.