How To Use CPT Code 45386

CPT 45386 describes the procedure of colonoscopy with transendoscopic balloon dilation. 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 45386?

CPT 45386 is used to describe a specific procedure called colonoscopy with transendoscopic balloon dilation. This procedure involves the use of a colonoscope, a long, thin flexible tube with a light source and camera, to examine the inner part of the colon and rectum. During the procedure, a balloon catheter is introduced through the scope and inflated at one or more sites of stricture, which are areas of abnormal narrowing in the colon. The dilation helps to open up the narrowed lumen and improve the patient’s condition.

2. Official Description

The official description of CPT code 45386 is: ‘Colonoscopy, flexible; with transendoscopic balloon dilation.’ It is important to note that this code should not be reported in conjunction with codes 45378, 45388, or 45389. If fluoroscopic guidance is performed during the procedure, code 74360 should be used. Additionally, if multiple strictures are dilated during the same session, modifier 59 should be appended to code 45386 for each additional stricture dilated.

3. Procedure

1. The provider begins the procedure by appropriately prepping and anesthetizing the patient.
2. A colonoscope is inserted through the anus and advanced beyond the splenic flexure, which is a bend in the colon.
3. The provider inspects the lumen of the colon and rectum, checking for strictures.
4. If a stricture is found, a balloon catheter is introduced through a channel in the scope and inflated at the site of stricture.
5. The balloon dilation helps to open up the narrowed lumen and improve the patient’s condition.
6. The provider repeats this procedure for all the strictures that are found.
7. Once the necessary dilations are completed, the provider deflates the balloon and removes the scope and balloon catheter.

4. Qualifying circumstances

CPT 45386 is typically performed on patients who have strictures in their colon that require dilation. These strictures can cause abnormal narrowing and may lead to symptoms such as pain, obstruction, or difficulty passing stool. The procedure is performed by a qualified healthcare provider who is trained in performing colonoscopies and balloon dilations. It is important to note that CPT 45386 should not be reported with codes 45378, 45388, or 45389, as these codes represent different procedures.

5. When to use CPT code 45386

CPT code 45386 should be used when a colonoscopy is performed with transendoscopic balloon dilation. This code is appropriate when the provider uses a balloon catheter to dilate one or more strictures during the procedure. It is important to ensure that the documentation supports the use of this code and that it is not reported in conjunction with other codes that represent different procedures.

6. Documentation requirements

To support a claim for CPT code 45386, the provider must document the following information:

• Patient’s diagnosis and the presence of strictures in the colon
• Description of the procedure performed, including the use of a colonoscope and balloon catheter
• Date of the procedure
• Specific sites of stricture dilation
• Any additional procedures or interventions performed during the same session
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 45386, it is important to ensure that the documentation supports the use of this code and that it is not reported with codes 45378, 45388, or 45389. If fluoroscopic guidance is performed during the procedure, code 74360 should be used in addition to code 45386. If multiple strictures are dilated during the same session, modifier 59 should be appended to code 45386 for each additional stricture dilated. It is important to follow the specific guidelines provided by the payer and to accurately report the services provided.

8. Historical information

CPT code 45386 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 dilation by balloon, 1 or more strictures.’

9. Examples

1. A patient undergoes a colonoscopy with transendoscopic balloon dilation to treat a stricture in their colon.
2. During a colonoscopy, the provider identifies multiple strictures and performs balloon dilation at each site.
3. A patient with symptoms of pain and obstruction undergoes a colonoscopy with transendoscopic balloon dilation to relieve the narrowing in their colon.
4. A follow-up colonoscopy is performed on a patient who previously had a stricture in their colon, and balloon dilation is performed to ensure the stricture has not recurred.
5. A patient with a history of strictures in their colon undergoes a colonoscopy with transendoscopic balloon dilation as part of their regular surveillance.