How To Use CPT Code 45392

CPT 45392 describes the procedure of transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) during a flexible colonoscopy. 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 45392?

CPT 45392 is used to describe a specific procedure that involves the use of a flexible colonoscope to perform transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s). This procedure allows the provider to examine the colon, rectum, sigmoid, descending, transverse, or ascending colon, the cecum, and adjacent structures, and obtain samples of abnormal tissue for further analysis.

2. Official Description

The official description of CPT code 45392 is: ‘Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures.’

3. Procedure

1. The provider begins by inserting a flexible colonoscope through the anus and advances it to the cecum.
2. Using the colonoscope, the provider inspects the lumen of the colon and rectum, checking for the presence of abnormal tissue.
3. An ultrasound probe is then introduced through a channel in the scope, allowing the provider to perform an ultrasound examination of the colon and adjacent structures.
4. Under ultrasound guidance, the provider inserts a fine gauge needle through the scope and aspirates a fluid sample consisting of cells from the area of the lesion or tumor.
5. If necessary, the provider may also remove samples of abnormal tissue for biopsy.
6. Once the procedure is complete, the provider removes the ultrasound probe and the colonoscope.

4. Qualifying circumstances

CPT 45392 is performed when there is a need for transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) during a flexible colonoscopy. This procedure is typically used to obtain samples of abnormal tissue for further analysis, such as in cases of suspected tumors or lesions in the colon or adjacent structures.

5. When to use CPT code 45392

CPT code 45392 should be used when the provider performs a flexible colonoscopy and utilizes transendoscopic ultrasound guidance to perform intramural or transmural fine needle aspiration/biopsy(s). This code should not be reported in conjunction with other codes such as 45378, 45391, 76872, 76942, or 76975. It should also not be reported more than once per session.

6. Documentation requirements

To support a claim for CPT 45392, the provider must document the following information:

• Indication for the procedure and the need for transendoscopic ultrasound guidance
• Specific details of the procedure performed, including the use of fine needle aspiration/biopsy(s)
• Date and duration of the procedure
• Location of the ultrasound examination and any abnormalities identified
• Details of the samples obtained, including the site and method of aspiration/biopsy
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 45392, ensure that the procedure meets the criteria for transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) during a flexible colonoscopy. It should not be reported with other specific codes mentioned earlier. It is important to follow the guidelines provided by the payer and include any necessary modifiers or additional documentation to support the claim.

8. Historical information

CPT 45392 was added to the Current Procedural Terminology system on January 1, 2005. There was a code change on January 1, 2015, which modified the description of the procedure to include the term “proximal to splenic flexure.”

9. Examples

1. A gastroenterologist performing a flexible colonoscopy with transendoscopic ultrasound guided intramural fine needle aspiration of a suspected tumor in the ascending colon.
2. An oncologist utilizing a flexible colonoscopy with transendoscopic ultrasound guided transmural fine needle biopsy to obtain samples of abnormal tissue in the rectum for further analysis.
3. A surgeon performing a flexible colonoscopy with transendoscopic ultrasound guided intramural fine needle aspiration/biopsy(s) to investigate a lesion in the sigmoid colon.
4. A gastroenterologist utilizing a flexible colonoscopy with transendoscopic ultrasound guided intramural fine needle aspiration to obtain samples of abnormal tissue in the descending colon.
5. An interventional radiologist performing a flexible colonoscopy with transendoscopic ultrasound guided transmural fine needle biopsy to investigate a suspected tumor in the cecum.
6. A gastroenterologist utilizing a flexible colonoscopy with transendoscopic ultrasound guided intramural fine needle aspiration/biopsy(s) to obtain samples of abnormal tissue in the rectum for further analysis.
7. A surgeon performing a flexible colonoscopy with transendoscopic ultrasound guided intramural fine needle aspiration/biopsy(s) to investigate a lesion in the sigmoid colon.
8. An oncologist utilizing a flexible colonoscopy with transendoscopic ultrasound guided transmural fine needle biopsy to obtain samples of abnormal tissue in the descending colon.