2025 CPT code 45334
(Active) Effective Date: N/A Revision Date: N/A Surgery - Endoscopy Surgery Feed
Flexible sigmoidoscopy with control of bleeding using any method.
Modifiers 52 (reduced services) and 53 (discontinued procedure) may be applicable in certain circumstances. Consult the CPT manual for appropriate modifier use.
Medical necessity for 45334 is established when the patient presents with active lower gastrointestinal bleeding requiring endoscopic evaluation and treatment.The procedure is medically necessary to diagnose and control the bleeding, preventing potentially life-threatening complications.
The physician inserts a sigmoidoscope, examines the rectum and sigmoid colon, identifies the source of bleeding, and employs a suitable method to control the hemorrhage. Post-procedure care and monitoring are also included in clinical responsibility.
In simple words: The doctor uses a thin, flexible tube with a camera and light (sigmoidoscope) to examine the rectum and sigmoid colon (part of the large intestine). If there's bleeding, they stop it using different methods like heat, injection, or other tools.
This CPT code encompasses flexible sigmoidoscopy with the control of any bleeding encountered during the procedure.The procedure involves the insertion of a flexible sigmoidoscope into the rectum and sigmoid colon to visualize and treat bleeding.Control of bleeding may be achieved through various methods, including injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, or plasma coagulator.The extent of the examination is typically limited to the rectum and sigmoid colon, and may include a portion of the descending colon up to the splenic flexure.
Example 1: A 65-year-old male presents with bright red rectal bleeding.Flexible sigmoidoscopy reveals a small angiodysplasia in the sigmoid colon. The physician uses bipolar cautery to control the bleeding., A 40-year-old female reports intermittent rectal bleeding after a bowel movement. Sigmoidoscopy identifies a small diverticular bleed; injection therapy is used to successfully stop the bleeding., A 72-year-old patient with a history of inflammatory bowel disease experiences heavy rectal bleeding. Sigmoidoscopy shows extensive inflammation and active bleeding in the sigmoid colon, requiring multiple applications of a heater probe for hemostasis.
** This code includes the control of bleeding, regardless of the method used.The documentation must clearly specify the method used for accurate coding.If the bleeding is not controlled, modifier 53 should be used.
- Revenue Code: P8C (ENDOSCOPY - SIGMOIDOSCOPY)
- Payment Status: Active
- Modifier TC rule: The TC modifier is not applicable to this code.
- Specialties:Gastroenterology, Colorectal Surgery, General Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center