2025 CPT code 45341
(Active) Effective Date: N/A Revision Date: N/A Surgery - Endoscopy Surgery Feed
Flexible sigmoidoscopy with endoscopic ultrasound examination.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., modifier 52 for reduced services, modifier 53 for discontinued procedure). Consult the CPT codebook for specific guidance.
Medical necessity for a flexible sigmoidoscopy with endoscopic ultrasound is established when there is clinical suspicion of pathology in the rectum or sigmoid colon, such as bleeding, changes in bowel habits, abdominal pain, or a family history of colon cancer.The addition of the ultrasound component is medically necessary for better tissue characterization and improved diagnostic accuracy.
The physician is responsible for inserting the sigmoidoscope, performing the endoscopic examination, introducing and operating the ultrasound probe, interpreting the ultrasound images, and providing a diagnosis based on the findings.
In simple words: The doctor uses a thin, flexible tube with a camera to look inside the rectum and lower colon.An ultrasound probe is then passed through the tube to take pictures of the area with sound waves, helping diagnose any problems.
This procedure involves a flexible sigmoidoscopy with an integrated endoscopic ultrasound examination.The physician inserts a flexible sigmoidoscope through the anus, advancing it into the rectum and sigmoid colon, possibly examining a portion of the descending colon up to the splenic flexure.During the examination, the physician assesses for any abnormalities. An ultrasound probe is then introduced through the sigmoidoscope's channel to perform an ultrasound examination of the colon, aiding in diagnosis. Following the procedure, the probe and scope are carefully removed.
Example 1: A patient presents with rectal bleeding and abdominal pain.A flexible sigmoidoscopy with endoscopic ultrasound is performed to evaluate the cause of the bleeding and assess the extent of any underlying pathology such as polyps, tumors or inflammatory bowel disease., A patient with a history of colon cancer undergoes a follow-up examination to monitor for recurrence.A flexible sigmoidoscopy with endoscopic ultrasound is used to visualize the rectum and sigmoid colon and detect any suspicious lesions., A patient experiencing chronic constipation and changes in bowel habits undergoes a flexible sigmoidoscopy with endoscopic ultrasound to rule out any structural abnormalities causing these symptoms, such as strictures or tumors.The ultrasound component allows for better tissue characterization.
* Pre-procedure consent form signed by the patient.* Detailed history and physical examination documenting the reason for the procedure.* Images and reports from the endoscopic ultrasound examination.* Pathology reports (if any tissue samples were taken).* Anesthesia records if applicable.* Post-operative instructions given to the patient.
** The use of endoscopic ultrasound in conjunction with sigmoidoscopy significantly enhances the diagnostic capabilities of the procedure, allowing for better visualization and characterization of lesions. This is particularly helpful in cases where biopsy alone may not provide sufficient information.
- Revenue Code: P8C (ENDOSCOPY - SIGMOIDOSCOPY)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Gastroenterology, Colorectal Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital