How To Use CPT Code 45389

CPT 45389 describes the procedure of flexible colonoscopy with endoscopic stent placement, including pre- and post-dilation and guide wire passage if necessary. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 45389?

CPT 45389 is used to describe a specific procedure involving flexible colonoscopy and the placement of an endoscopic stent. This code encompasses the entire process, including pre- and post-dilation and the passage of a guide wire if required. It is important to note that CPT 45389 should not be reported in conjunction with CPT codes 45378 or 45386. If fluoroscopic guidance is performed during the procedure, CPT code 74360 should be used.

2. Official Description

The official description of CPT code 45389 is: ‘Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed).’ It is important to remember that this code should not be reported if CPT codes 45378 or 45386 are already performed.

3. Procedure

1. During the procedure, the provider performs a flexible colonoscopy to examine the colon for any obstructions or strictures.
2. If an obstruction or stricture is identified, the provider determines the length of the stent needed for the patient.
3. The provider may use a guide wire to assist with introducing the stent and may perform dilation of the site before or after stent placement.
4. Using an endoscopic approach, the provider places the stent at the site of obstruction to relieve the stricture.
5. If the obstruction is severe, the provider may also place a balloon catheter at the site and inflate it to remove the obstruction.
6. Once the stent is placed or the obstruction is resolved, the provider removes the colonoscope.

4. Qualifying circumstances

CPT 45389 is performed on patients who have obstructions or strictures in the colon that require the placement of an endoscopic stent. The procedure is typically performed by a provider who is experienced in performing colonoscopies and stent placements. It is important to note that CPT 45389 should not be reported if CPT codes 45378 or 45386 are already performed.

5. When to use CPT code 45389

CPT code 45389 should be used when a provider performs a flexible colonoscopy and places an endoscopic stent in a patient with an obstruction or stricture in the colon. It is important to ensure that the procedure includes pre- and post-dilation and guide wire passage, if necessary. If fluoroscopic guidance is performed during the procedure, CPT code 74360 should be used instead.

6. Documentation requirements

To support a claim for CPT code 45389, the provider must document the following information:

• Patient’s diagnosis indicating the presence of an obstruction or stricture in the colon
• Details of the procedure, including pre- and post-dilation and guide wire passage, if performed
• Date of the procedure
• Length of the stent placed
• Any additional procedures performed, such as balloon catheter placement
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 45389, it is important to ensure that the procedure includes all the necessary components, such as pre- and post-dilation and guide wire passage. This code should not be reported if CPT codes 45378 or 45386 are already performed. If fluoroscopic guidance is used during the procedure, CPT code 74360 should be reported instead. It is important to follow the specific guidelines provided by the payer to ensure accurate and appropriate billing.

8. Historical information

CPT code 45389 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates or changes to the code since its addition.

9. Examples

1. A gastroenterologist performing a flexible colonoscopy and placing an endoscopic stent to relieve an obstruction in a patient with colon cancer.
2. A general surgeon performing a flexible colonoscopy and placing an endoscopic stent to treat a patient with a colonic stricture caused by Crohn’s disease.
3. An interventional radiologist performing a flexible colonoscopy and placing an endoscopic stent to relieve an obstruction in a patient with diverticulitis.
4. A colorectal surgeon performing a flexible colonoscopy and placing an endoscopic stent to treat a patient with a colonic stricture caused by radiation therapy.
5. An oncologist performing a flexible colonoscopy and placing an endoscopic stent to relieve an obstruction in a patient with metastatic colon cancer.
6. A gastroenterologist performing a flexible colonoscopy and placing an endoscopic stent to treat a patient with a colonic stricture caused by ischemic colitis.
7. An interventional radiologist performing a flexible colonoscopy and placing an endoscopic stent to relieve an obstruction in a patient with a colonic stricture caused by an inflammatory bowel disease.
8. A general surgeon performing a flexible colonoscopy and placing an endoscopic stent to treat a patient with a colonic stricture caused by a benign tumor.
9. An oncologist performing a flexible colonoscopy and placing an endoscopic stent to relieve an obstruction in a patient with advanced colorectal cancer.
10. A gastroenterologist performing a flexible colonoscopy and placing an endoscopic stent to treat a patient with a colonic stricture caused by an anastomotic leak.