CPT Code 45385: Colonoscopy with Polypectomy using Snare Technique

What is CPT code 45385?

CPT code 45385 is used to report a colonoscopy procedure involving the removal of one or more polyps using a snare technique. This technique allows the endoscopist to loop and excise polyps, often through electrocautery. It applies whether the procedure is performed for a diagnostic indication or begins as a colorectal cancer screening but results in therapeutic action.

This code is frequently billed during colonoscopies performed on average-risk screening patients, where a polyp is discovered and removed. While the initial intent may have been preventive, the service becomes diagnostic or therapeutic once a polyp is removed. In such cases, it’s essential to use the correct procedure code and apply the appropriate modifiers to reflect the screening intent of the service.

Documentation requirements

To support billing CPT 45385, documentation should reflect that:

• The colonoscopy reached the cecum or the full extent of the colon;
• A polyp was identified and removed using a snare device, with or without electrocautery;
• The size, location, and number of polyps removed are recorded;
• The indication for the colonoscopy is stated—whether it was ordered for screening, diagnostic, or surveillance purposes.

If the procedure started as a screening colonoscopy, the provider must also document the patient's risk level (e.g., average risk vs high risk) and the transition from screening to therapeutic intervention. This distinction supports correct coding and modifier use, especially for Medicare beneficiaries.

Billing guidelines

Although the procedure may begin as a preventive service, once a polyp is removed using a snare, it becomes diagnostic or therapeutic, and this impacts both the CPT code reported and the modifiers applied. Accurate documentation and appropriate use of diagnosis codes and modifiers are essential to ensure compliance and correct reimbursement, particularly when billing for Medicare beneficiaries or commercial insurance plans with specific preventive care policies.

Use of CPT 45385

CPT 45385 should be reported when a colonoscopy results in removing polyp(s) using a snare loop. It is a therapeutic procedure code that precedes diagnostic or screening codes when therapeutic intervention occurs. It can be billed regardless of the number of polyps removed by the snare technique.

Screening vs diagnostic intent

If the colonoscopy began as a colorectal cancer screening and a polyp was removed using a snare, bill CPT 45385 and:

• Append modifier PT for Medicare patients to indicate that the procedure started as a screening but became therapeutic.
• When applicable, use modifier 33 for commercial payers to preserve the patient’s preventive benefits.

Common billing issues

Avoid reporting CPT 45385 as a separate procedure from the colonoscopy—it is inherently bundled. Also, do not use this code if a polyp is removed by cold biopsy or hot forceps; use 45384 in those cases. Always ensure the procedure was performed by the same physician as documented.

Other relevant CPT codes

• 45378: Screening colonoscopy (no polyps removed)
• 45380: Colonoscopy, flexible; with biopsy, single or multiple