How To Use CPT Code 45388

CPT 45388 describes the procedure for flexible colonoscopy with ablation of tumor(s), polyp(s), or other lesion(s). This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45388?

CPT 45388 is used to describe the procedure of flexible colonoscopy with the purpose of destroying one or more tumors, polyps, or other lesions. This code includes pre- and post-dilation, as well as guide wire passage if necessary.

2. Official Description

The official description of CPT code 45388 is: ‘Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed).’ It is important to note that CPT 45388 should not be reported in conjunction with CPT 45386 for the same lesion, or with CPT 45378.

3. Procedure

1. The provider begins by appropriately prepping and anesthetizing the patient.
2. A flexible colonoscope is inserted by the provider to visualize the colon and identify any tumors, polyps, or lesions.
3. The provider performs ablation of the identified lesions using various methods to destroy the abnormal tissue.
4. If necessary, the provider may perform pre- and post-dilation at the site, as well as guide wire passage during the procedure.
5. The provider ensures hemostasis and removes the scope.

4. Qualifying circumstances

CPT 45388 is used when a patient requires ablation of tumor(s), polyp(s), or other lesion(s) during a flexible colonoscopy. The procedure is performed by a qualified provider and may involve pre- and post-dilation, as well as guide wire passage if necessary.

5. When to use CPT code 45388

CPT code 45388 should be used when a flexible colonoscopy is performed with the specific purpose of ablating tumor(s), polyp(s), or other lesion(s). It is important to note that CPT 45388 should not be reported in conjunction with CPT 45386 for the same lesion, or with CPT 45378.

6. Documentation requirements

To support a claim for CPT 45388, the provider must document the following information:

• Patient’s diagnosis and the need for ablation of tumor(s), polyp(s), or other lesion(s)
• Details of the procedure, including pre- and post-dilation, guide wire passage, and the methods used for ablation
• Date and duration of the procedure
• Any complications or additional interventions performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 45388, ensure that the procedure meets the specific criteria outlined in the official description. It is important to note that CPT 45388 should not be reported in conjunction with CPT 45386 for the same lesion, or with CPT 45378. Additional tips for reporting CPT 45388 include:

• If the provider approaches the colon through a stoma, report CPT 44401 instead.
• If the provider uses hot biopsy forceps, report CPT 45384 instead.
• If the provider uses the snare technique, report CPT 45385 instead.

8. Historical information

CPT 45388 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a flexible colonoscopy and ablates a tumor in the colon.
2. During a flexible colonoscopy, a provider identifies and ablates multiple polyps.
3. A patient undergoes a flexible colonoscopy, and the provider performs ablation of a lesion in the colon.
4. During a flexible colonoscopy, a provider identifies and ablates a tumor in the rectum.
5. A patient undergoes a flexible colonoscopy, and the provider performs ablation of multiple polyps in the colon.
6. A provider performs a flexible colonoscopy and ablates a lesion in the rectum.
7. During a flexible colonoscopy, a provider identifies and ablates a tumor in the sigmoid colon.
8. A patient undergoes a flexible colonoscopy, and the provider performs ablation of multiple polyps in the sigmoid colon.
9. A provider performs a flexible colonoscopy and ablates a lesion in the ascending colon.
10. During a flexible colonoscopy, a provider identifies and ablates a tumor in the descending colon.