Colonoscopy Billing Guidelines

A Colonoscopy is an exam that allows a doctor to closely look at the inside of the entire colon. The doctor is looking for polyps or signs of cancer. Polyps are small growths that over time can become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a colonoscope.

Colonoscopy Codes

CPT Code
Description
45378
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
45379
Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body
45380
Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381
Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45382
Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45383
Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45384
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45378 – Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without collection colon decompression (separate procedure).  Because this code is diagnostic and a separate procedure, it should never be reported with any other colonoscopy code.  Per the CPT manual, when a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported.  Only when the provider performs a diagnostic colonoscopy with brushings, washings and/or decompression and nothing else (no biopsies, excisions, etc.) should this code be reported.

45380 – Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. The physician performs colonoscopy and obtains tissue samples.  This code can only be reported once regardless of the number of biopsies.  According to CPT Assistant, July 2004, this code is also used to describe polypectomy with cold biopsy forceps.  A cold biopsy with forceps is not the same as hot biopsy forceps and it is not a snare technique, therefore codes 45384 and 45385 would not be appropriate.  If the physician does remove a polyp or other lesion with a different technique and then takes a biopsy on a separate lesion, this code may be reported in addition with modifier -59. 

45381 – Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injections(s), any substance. The physician injects a substance into the submucosa, directed at specific areas through the scope while viewing the colon. (E.g. saline, India Ink).  This code is not to be used for injections used to control bleeding.  45381 may be reported in addition to other procedures with modifier -51 or -59. 

45382 – Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g. injections, laser, stapling, plasma coagulator).  This code is used when a physician controls bleeding in the colon due to a condition such as diverticulosis.  This code is not used to report control of bleeding caused by a procedure performed during the same encounter.  For example, there may be small amount of bleeding after a polyp is excised.   This would not be reported because control of bleeding is integral to therapeutic or surgical procedures.  However, if the physician treated a bleeding condition and then removed a polyp at a different location, the services may be reported together with modifier -59. 

45383 – Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cuatery or snare technique.  This code is used when a physician ablates tumors, polyps or other lesions by laser or other method (e.g. fulguration).   

45384 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cuatery.  Hot biopsy forceps (also called monopolar cautery forceps) have “jaws” that are between 1 and 2 mm in size and can open up to about 1 cm wide to encompass a small polyp or lesion. The physician then applies cautery to ablate the base of the polyp (or other lesion) so it can be retrieved and sent to pathology for analysis. 

45385 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.  Snaring involves “lassoing” a polyp or lesion with a wire loop and shaving it off the bowel wall.  The snare may or may not be heated.  Any snare technique including cold snare, hot snare, and bipolar snare would be reported with this code.  The snare technique is the most often used technique and is best when removing both sessile polyps (those attached by a large base) and pedunculated polyps (those attached by a stalk).

Coding Multiple Procedures

When more than one procedure is performed using the same technique, report only one code.  For example, if the physician removes multiple polyps throughout the colon with snare technique, 45385 can be reported only once. 

However, if multiple polyps or lesions are removed with different techniques, you may report each separately.  For example, a physician removes a polyp with snare technique in the rectum and then biopsies a lesion in the transverse colon, you may report 45385 and 45380-59. 

In the absence of a CCI edit, always list the procedure with the highest RVU first.