How To Use CPT Code 45390

CPT 45390 describes the procedure of flexible colonoscopy with endoscopic mucosal resection. 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 45390?

CPT 45390 is used to describe the procedure of flexible colonoscopy with endoscopic mucosal resection. It involves the use of a flexible colonoscope, which is a long, narrow tube with a light and camera on one end, to examine the colon and remove damaged or diseased tissue through excision. This code should be used when the provider performs both the colonoscopy and the excision of mucous membrane tissue using an endoscope.

2. Official Description

The official description of CPT code 45390 is: ‘Colonoscopy, flexible; with endoscopic mucosal resection.’ It is important to note that this code should not be reported in conjunction with codes 45380, 45381, 45385, or 45398 for the same lesion, and it should not be reported with code 45378.

3. Procedure

1. The provider begins by appropriately prepping and anesthetizing the patient.
2. Next, a flexible colonoscope is inserted into the colon to examine it for any lesions or areas of damaged or diseased tissue.
3. If a lesion is identified, the provider administers a submucosal injection to raise the lesion, making it easier to excise.
4. The provider then uses a snare or other means to excise the lesion.
5. In some cases, the provider may need to repeat the submucosal injection for deep lesions.
6. After the excision, the provider ensures hemostasis and removes the colonoscope.

4. Qualifying circumstances

CPT 45390 is typically performed on patients who require the removal of mucous membrane tissue in the colon. The procedure is indicated for patients with lesions or areas of damaged or diseased tissue that can be safely excised using an endoscope. It is important to note that this code should not be reported with other codes for the same lesion or with code 45378.

5. When to use CPT code 45390

CPT code 45390 should be used when the provider performs a flexible colonoscopy and excision of mucous membrane tissue using an endoscope. It is important to ensure that the procedure meets the specific criteria outlined in the code description. This code should not be used in conjunction with other codes for the same lesion or with code 45378.

6. Documentation requirements

To support a claim for CPT code 45390, the provider must document the following information:

• Patient’s prepping and anesthesia
• Use of a flexible colonoscope
• Identification of lesions or areas of damaged or diseased tissue
• Administration of submucosal injection
• Excision of the lesion using a snare or other means
• Hemostasis
• Removal of the colonoscope

7. Billing guidelines

When billing for CPT code 45390, ensure that the procedure meets the specific criteria outlined in the code description. It should not be reported with other codes for the same lesion or with code 45378. It is important to follow the guidelines provided by the payer and to use appropriate modifiers if necessary.

8. Historical information

CPT code 45390 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 excision of mucous membrane tissue using an endoscope to remove a lesion in the colon.
2. During a colonoscopy, the provider identifies an area of damaged tissue and performs an endoscopic mucosal resection to remove it.
3. A patient undergoes a flexible colonoscopy with endoscopic mucosal resection to remove a polyp in the colon.
4. The provider performs a colonoscopy and excises a lesion using an endoscope to ensure the patient’s health and well-being.
5. During a routine colonoscopy, the provider identifies a tumor and performs an endoscopic mucosal resection to remove it.
6. A patient with a history of colon cancer undergoes a flexible colonoscopy with endoscopic mucosal resection to remove any remaining cancerous tissue.
7. The provider performs a flexible colonoscopy and excises a lesion using an endoscope to prevent further complications.
8. During a colonoscopy, the provider identifies an area of damaged mucosa and performs an endoscopic mucosal resection to improve the patient’s health.
9. A patient with a family history of colon polyps undergoes a flexible colonoscopy with endoscopic mucosal resection to remove any potential polyps.
10. The provider performs a routine colonoscopy and excises a lesion using an endoscope to ensure the patient’s well-being.