How To Use CPT Code 45391

CPT 45391 describes the use of a colonoscope to perform an endoscopic ultrasound examination in the rectum, sigmoid, descending, transverse, or ascending colon and cecum, along with adjacent structures. This article will provide an overview of CPT code 45391, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 45391?

CPT 45391 is a code used to describe the utilization of a colonoscope for an endoscopic ultrasound examination in specific areas of the colon and adjacent structures. This procedure allows healthcare professionals to visualize and assess the rectum, sigmoid, descending, transverse, or ascending colon, as well as the cecum. It is an important diagnostic tool for evaluating conditions such as colon cancer.

2. Official Description

The official description of CPT code 45391 is: ‘Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures.’

3. Procedure

1. During the procedure, a qualified healthcare provider inserts a colonoscope, a long, thin, flexible tube with a light source and camera, through the anus and advances it to the cecum.
2. The provider carefully examines the lumen of the colon and rectum, looking for any abnormal tissue or lesions.
3. To perform the endoscopic ultrasound examination, the provider introduces an ultrasound probe through a channel in the colonoscope.
4. The ultrasound probe emits high-frequency sound waves, which create detailed images of the colon and adjacent structures.
5. The provider moves the colonoscope and ultrasound probe along the colon, capturing images and assessing the area of interest.
6. Once the examination is complete, the provider removes the ultrasound probe and the colonoscope.

4. Qualifying circumstances

CPT code 45391 is used when a healthcare professional performs an endoscopic ultrasound examination limited to specific areas of the colon and adjacent structures. This procedure is typically indicated for diagnostic purposes, such as evaluating suspected colon cancer or assessing the extent of a known lesion. It should not be reported in conjunction with other colonoscopy codes or certain ultrasound codes.

5. When to use CPT code 45391

CPT code 45391 should be used when a healthcare professional performs an endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, along with adjacent structures. It is important to note that this code should not be reported more than once per session and should not be reported with other specific colonoscopy or ultrasound codes.

6. Documentation requirements

To support a claim for CPT code 45391, the healthcare professional must document the following information:

• Indication for the procedure, including the reason for performing the endoscopic ultrasound examination
• Specific areas of the colon and adjacent structures examined
• Date and duration of the procedure
• Findings, including any abnormalities or lesions identified
• Any additional procedures or interventions performed during the same session
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT code 45391, ensure that the procedure meets the criteria outlined in the official description. It should be reported only once per session and should not be reported in conjunction with other specific colonoscopy or ultrasound codes. It is important to review the documentation requirements and ensure accurate and complete documentation to support the claim.

8. Historical information

CPT code 45391 was added to the Current Procedural Terminology system on January 1, 2005. There have been historical changes to the code, including a code change on January 1, 2015, which added the specification of the examination being limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures.

9. Examples

1. A gastroenterologist performing an endoscopic ultrasound examination limited to the rectum and sigmoid colon to evaluate a suspected lesion.
2. A colorectal surgeon using a colonoscope to perform an endoscopic ultrasound examination of the descending colon and adjacent structures to assess the extent of a known tumor.
3. An oncologist performing an endoscopic ultrasound examination limited to the transverse colon and cecum to stage a newly diagnosed colon cancer.
4. A gastroenterologist utilizing a colonoscope for an endoscopic ultrasound examination of the ascending colon and adjacent structures to evaluate a patient with unexplained abdominal pain.
5. A general surgeon performing an endoscopic ultrasound examination limited to the rectum, sigmoid, and descending colon to assess the response to treatment in a patient with inflammatory bowel disease.
6. A gastroenterologist using a colonoscope to perform an endoscopic ultrasound examination of the transverse colon and adjacent structures to evaluate a patient with a history of polyps.
7. An oncologist performing an endoscopic ultrasound examination limited to the ascending colon and cecum to assess the resectability of a known tumor.
8. A colorectal surgeon utilizing a colonoscope for an endoscopic ultrasound examination of the rectum and sigmoid colon to evaluate a patient with a family history of colon cancer.
9. A gastroenterologist performing an endoscopic ultrasound examination limited to the descending colon and adjacent structures to evaluate a patient with unexplained weight loss.
10. An oncologist using a colonoscope to perform an endoscopic ultrasound examination of the transverse colon and cecum to assess the response to chemotherapy in a patient with advanced colon cancer.