2025 CPT code 45308
(Active) Effective Date: N/A Revision Date: N/A Surgery - Endoscopy Procedures on the Rectum Surgery Feed
Proctosigmoidoscopy, rigid; with removal of a single tumor, polyp, or other lesion using hot biopsy forceps or bipolar cautery.
Modifiers 52 (reduced services) and 53 (discontinued procedure) may be applicable in certain scenarios as outlined in the CPT manual.
Medical necessity is established by the presence of symptoms (e.g., rectal bleeding, changes in bowel habits) suggestive of a pathology requiring diagnostic evaluation or removal, or a routine screening based on age and risk factors.
The physician is responsible for prepping the patient, administering anesthesia (if necessary), inserting the scope, visualizing the rectum and sigmoid colon, identifying and removing the lesion, and ensuring appropriate post-procedure care.
In simple words: The doctor examines the inside of the anus, rectum, and lower part of the large intestine using a short, rigid tube with a camera.They then remove a single abnormal growth using a special tool.
This procedure involves a rigid proctosigmoidoscopic examination of the anus, rectum, and sigmoid colon.A single tumor, polyp, or other lesion is removed using hot biopsy forceps or bipolar cautery. The procedure requires appropriate patient preparation and anesthesia.The physician inserts a rigid scope through the anus, advances it to visualize the anal canal, rectum, and sigmoid colon, and removes the identified lesion using the chosen technique. The scope is then withdrawn.
Example 1: A 60-year-old male presents with rectal bleeding.Proctosigmoidoscopy reveals a single polyp in the rectum. The polyp is removed using hot biopsy forceps., A 55-year-old female undergoes a screening colonoscopy. A single, small, benign polyp is found in the sigmoid colon.It is removed using bipolar cautery., A 72-year-old male presents with a suspected rectal tumor.A rigid proctosigmoidoscopy is performed, and a single lesion is removed using hot biopsy forceps. The tissue is sent to pathology.
* Pre-procedure patient assessment and preparation notes.* Anesthesia records (if applicable).* Detailed operative report documenting the procedure, including the location, size, and number of lesions removed.* Pathology report (if applicable).* Post-procedure patient assessment and instructions.
** The choice of hot biopsy forceps or bipolar cautery depends on the physician's preference and the characteristics of the lesion.Appropriate documentation is crucial for accurate coding and reimbursement.
- Payment Status: Active
- Specialties:Gastroenterology, Colorectal Surgery, General Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center