CPT Code 45380: Colonoscopy with Biopsy

What is CPT code 45380?

CPT code 45380 describes a colonoscopy with biopsy. Specifically, it refers to a colonoscopy, flexible, with biopsy, single or multiple. This screening colonoscopy procedure involves visual examination of the large intestine (colon) from the rectum to the cecum or terminal ileum using a flexible endoscope and collecting tissue samples for further analysis. Unlike the base colonoscopy procedure code (CPT 45378), code 45380 includes the additional work of obtaining tissue samples via forceps biopsy.

Clinical indications

The medical necessity for a colonoscopy with biopsy may be established through various clinical scenarios, including:

• Follow-up to a positive result on other colorectal cancer screening tests, such as fecal immunochemical tests (FIT) or fecal occult blood tests (FOBT).
• Evaluation of abnormal findings on imaging studies.
• Assessment of inflammatory bowel diseases, such as ulcerative colitis.
• Surveillance for patients with a personal history or family history of colorectal cancer or polyps.
• Evaluation of unexplained gastrointestinal symptoms, including rectal bleeding, changes in bowel habits, or unexplained weight loss.

During a colonoscopy with biopsy, a physician inserts a flexible colonoscope through the rectum and advances it to the cecum or terminal ileum, examining the entire colon, including the splenic flexure. When suspicious lesions or abnormalities are identified, tissue samples are obtained using biopsy forceps. These samples are then sent to pathology for histological examination.

CPT code 45380 documentation requirements

Thorough documentation is essential for supporting medical necessity, ensuring proper coding, and maintaining compliance with regulatory requirements when reporting colonoscopy code 45380.

Pre-procedure documentation

The medical record for a colonoscopy with biopsy should include comprehensive pre-procedure documentation that clearly establishes the medical necessity for the procedure. This should detail the patient's presenting symptoms, relevant medical history (such as history of malignant neoplasm), and risk factors that warrant the colonoscopy and potential biopsy.

Any prior screening tests with positive results should be noted, along with family history of colorectal cancer or other relevant conditions. The documentation should also include a thorough physical examination, preventive services, previous diagnostic findings that support the need for colonoscopy, and proper informed consent that outlines the procedure's risks, benefits, and alternatives.

Procedure documentation

Detailed procedure documentation for CPT code 45380 must include the date of service, the name of the performing physician, and a comprehensive description of the procedure. The documentation should specify the extent of the examination, noting whether the colonoscope reached the cecum or terminal ileum, with specific mention of anatomical landmarks (such as the ileocecal valve or appendiceal orifice) to confirm complete visualization.

The record should include detailed descriptions of abnormalities found, their exact locations (by segment of colon), size, and appearance. For each biopsy taken, the documentation should specify the location, the reason for the biopsy, the technique used, and the number of specimens obtained.

Post-procedure documentation

Comprehensive post-procedure documentation for CPT code 45380 should include the immediate findings from the colonoscopy and biopsy, even if preliminary. The physician should document recommendations for further care based on these findings, including follow-up appointments, additional testing, or treatment plans based on the anticipated pathology results. Instructions to the patient regarding post-procedure care, diet restrictions, activity limitations, and medication adjustments should be detailed.

CPT code 45380 billing guidelines

Proper billing for colonoscopy with biopsy requires understanding the complex interplay between procedure codes, diagnosis codes, and applicable modifiers.

The billing approach for colonoscopy procedures varies significantly based on the intent of the procedure, whether it was performed as a screening or diagnostic service.

Screening colonoscopy

Special coding considerations apply when a colonoscopy is initially scheduled as a preventive screening for an asymptomatic average-risk patient. For Medicare beneficiaries, HCPCS codes (G codes) are often used instead of CPT codes for colorectal cancer screening. However, if a biopsy is performed during a screening colonoscopy, CPT code 45380 may be reported, typically with modifier 33 to indicate a preventive service. This ensures the patient is not subject to cost sharing for the procedure.

Diagnostic colonoscopy

When a colonoscopy is performed for diagnostic purposes, such as evaluating symptoms or following up on positive screening tests, CPT code 45380 is reported with the appropriate diagnosis code that reflects the medical necessity for the procedure.

Common ICD-10-CM codes used with diagnostic colonoscopies include:

• K92.2 (Gastrointestinal hemorrhage, unspecified)
• R19.5 (Other fecal abnormalities)
• K50.00-K50.919 (Crohn's disease)
• K51.00-K51.919 (Ulcerative colitis)

Medicare vs. commercial payers

Coding and billing requirements can differ significantly between Medicare and commercial payers. While Medicare often requires G codes for screening colonoscopies, commercial payers typically use CPT codes with modifier 33. Medicare contractors may have specific local coverage determinations (LCDs) that dictate coverage and coding requirements for colonoscopy procedures in the Medicare population.

Other relevant codes

When considering colonoscopy procedures, several related codes may be applicable depending on the specific services performed:

• 45378: Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
• 45381: Colonoscopy, flexible; with directed submucosal injection(s), any substance
• 45382: Colonoscopy, flexible; with control of bleeding, any method
• 45384: Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
• 45385: Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique