How To Use CPT Code 45398

CPT code 45398 describes the procedure of band ligation during a flexible colonoscopy. 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 45398?

CPT 45398 can be used to describe the procedure of band ligation during a flexible colonoscopy. This code is used when the provider uses a flexible band to ligate a structure, such as a hemorrhoid, in the colon. It is important to note that CPT 45398 should not be reported in conjunction with CPT 45382 for the same lesion, or with CPT 45378, 45390, or 46221. Additionally, CPT 45398 should not be reported more than once per session.

2. Official Description

The official description of CPT code 45398 is: ‘Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids).’ It is important to note the notes associated with this code, which state not to report 45398 in conjunction with 45382 for the same lesion, and not to report it with 45378, 45390, or 46221.

3. Procedure

1. During a flexible colonoscopy, the provider introduces a flexible colonoscope into the patient’s rectum and entire colon.
2. The provider uses the colonoscope to identify internal hemorrhoids or other structures that require treatment by ligation.
3. Once the structure is identified, the provider mobilizes it to locate the base.
4. The provider then tightly ligates the structure with a rubber band, aiming to stop the blood supply and cause tissue death.
5. Multiple ligations may be performed if necessary.
6. After the ligation procedure, the provider removes the colonoscope.

4. Qualifying circumstances

CPT 45398 is used when a provider performs band ligation during a flexible colonoscopy. This procedure is typically performed on patients with internal hemorrhoids or other structures in the colon that require treatment. The provider must be appropriately trained and qualified to perform the procedure.

5. When to use CPT code 45398

CPT code 45398 should be used when a provider performs band ligation during a flexible colonoscopy. It is important to ensure that the procedure meets the specific criteria outlined in the code description and notes. This code should not be reported in conjunction with certain other codes, as mentioned earlier.

6. Documentation requirements

To support a claim for CPT 45398, the provider must document the following information:

• The need for band ligation during the flexible colonoscopy
• The specific structures treated with band ligation
• Date and details of the procedure, including start and end times
• Any complications or additional procedures performed
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 45398, ensure that the procedure meets the specific criteria outlined in the code description and notes. It is important not to report this code in conjunction with certain other codes, as mentioned earlier. Additionally, consider any specific guidelines provided by payers regarding the use of this code.

8. Historical information

CPT 45398 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 gastroenterologist performing band ligation during a flexible colonoscopy to treat internal hemorrhoids.
2. A colorectal surgeon using band ligation to treat a bleeding lesion in the colon during a flexible colonoscopy.
3. An interventional radiologist performing band ligation to treat a vascular malformation in the colon during a flexible colonoscopy.
4. A general surgeon using band ligation to treat a polyp in the colon during a flexible colonoscopy.
5. An oncologist performing band ligation to treat a tumor in the colon during a flexible colonoscopy.
6. A gastroenterologist using band ligation to treat a bleeding arteriovenous malformation in the colon during a flexible colonoscopy.
7. A colorectal surgeon performing band ligation to treat a rectal prolapse during a flexible colonoscopy.
8. An interventional radiologist using band ligation to treat a bleeding angiodysplasia in the colon during a flexible colonoscopy.
9. A general surgeon performing band ligation to treat a diverticulum in the colon during a flexible colonoscopy.
10. An oncologist using band ligation to treat a tumor recurrence in the colon during a flexible colonoscopy.