How To Use CPT Code 45385

CPT 45385 refers to a colonoscopy procedure involving the removal of tumors, polyps, or other lesions using a snare technique. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 45385.

1. What is CPT 45385?

CPT 45385 is a medical code used to describe a specific type of colonoscopy procedure. This procedure involves the use of a flexible colonoscope to examine the colon and rectum, and the removal of tumors, polyps, or other lesions using a snare technique. The code is used by medical coders and billers to accurately document and bill for this procedure.

2. 45385 CPT code description

The official description of CPT code 45385 is: “Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.”

3. Procedure

The CPT 45385 procedure involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider inserts a colonoscope through the anus and advances it beyond the splenic flexure.
3. The provider inspects the lumen of the colon and rectum for the presence of abnormal tissue, such as tumors or polyps.
4. When a lesion is identified, the provider passes a wire loop (snare) around the base of the lesion and tightens it until the wire cuts through the lesion.
5. Once the procedure is complete, the provider withdraws the scope.

4. Qualifying circumstances

Patients eligible to receive CPT code 45385 services are those who have been diagnosed with or are suspected of having abnormal tissue growths, such as tumors, polyps, or other lesions, within their colon or rectum. This procedure may also be performed as part of a routine colon cancer screening for patients who meet specific age and risk criteria.

5. When to use CPT code 45385

It is appropriate to bill the 45385 CPT code when a provider performs a colonoscopy with the removal of tumor(s), polyp(s), or other lesion(s) using a snare technique. This code should be used to accurately document and bill for the specific procedure performed, ensuring proper reimbursement for the services provided.

6. Documentation requirements

To support a claim for CPT 45385, the following information should be documented:

• Patient’s medical history and reason for the procedure
• Details of the colonoscopy procedure, including the use of a snare technique for lesion removal
• Findings and results of the procedure, including the number, size, and location of lesions removed
• Any complications or additional interventions performed during the procedure
• Post-procedure care instructions and follow-up recommendations

7. Billing guidelines

When billing for CPT code 45385, it is important to follow the appropriate guidelines and rules to ensure accurate reimbursement. Some tips and codes that apply to CPT code 45385 include:

• Do not report CPT 45385 in conjunction with CPT 45390 for the same lesion.
• Do not report CPT 45385 in conjunction with CPT 45378.
• For endoscopic mucosal resection, use CPT 45390 instead of CPT 45385.

8. Historical information

CPT 45385 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 removal of tumor(s), polyp(s), or other lesion(s) by snare technique.”

9. Similar codes to CPT 45385

Five similar codes to CPT 45385 and how they differentiate from CPT 45385 are:

1. CPT 45378: This code is for a diagnostic colonoscopy without any removal of lesions.
2. CPT 45380: This code involves the removal of lesions using a biopsy forceps instead of a snare technique.
3. CPT 45381: This code is for a colonoscopy with submucosal injection, which is not included in CPT 45385.
4. CPT 45382: This code is for a colonoscopy with control of bleeding, which is not a part of CPT 45385.
5. CPT 45390: This code is for an endoscopic mucosal resection, which is a different technique than the snare technique used in CPT 45385.

10. Examples

Here are 10 detailed examples of CPT code 45385 procedures:

1. A 50-year-old patient undergoes a routine colonoscopy screening, and the provider removes two small polyps using a snare technique.
2. A patient with a history of colon polyps has a follow-up colonoscopy, during which the provider removes a 1 cm polyp using a snare technique.
3. A patient presents with rectal bleeding, and the provider performs a colonoscopy, removing a large sessile polyp using a snare technique.
4. A patient with a family history of colon cancer undergoes a colonoscopy, and the provider removes multiple small polyps using a snare technique.
5. A patient with persistent abdominal pain undergoes a colonoscopy, and the provider removes a pedunculated polyp using a snare technique.
6. A patient with a history of inflammatory bowel disease undergoes a colonoscopy, and the provider removes a flat lesion using a snare technique.
7. A patient with anemia undergoes a colonoscopy, and the provider removes a large polyp using a snare technique.
8. A patient with a positive fecal immunochemical test undergoes a colonoscopy, and the provider removes a sessile serrated polyp using a snare technique.
9. A patient with a history of Lynch syndrome undergoes a colonoscopy, and the provider removes multiple adenomatous polyps using a snare technique.
10. A patient with a change in bowel habits undergoes a colonoscopy, and the provider removes a villous adenoma using a snare technique.