2025 CPT code 45385
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
Modifiers are applicable. Modifier 33 is used for preventative services. Modifiers 52, 53, 59 and others may be applicable in specific scenarios.
In simple words: The doctor uses a long, flexible tube with a camera and light (a colonoscope) to look inside your colon and rectum. If they find any abnormal growths, like polyps or tumors, they'll use a small wire loop to remove them during the same procedure.This loop acts like a tiny lasso, cutting the growth away safely.
This code describes a procedure where a flexible colonoscope is inserted into the rectum to examine the colon. During the examination, any tumors, polyps, or other lesions found are removed using a snare technique. This involves passing a wire loop around the base of the growth and tightening it to sever the lesion from the colon wall.
Example 1: A patient presents for a screening colonoscopy. During the procedure, a single polyp is identified and removed using a snare technique. Code 45385-33 would be reported., During a diagnostic colonoscopy, the physician identifies multiple polyps. Two polyps are removed using snare technique, and one polyp is removed using hot biopsy forceps. Codes 45385 and 45384 would be reported., A patient with a history of colon cancer undergoes a surveillance colonoscopy. Several small polyps are found and removed via snare polypectomy. Code 45385 would be reported.
Documentation should include details of the procedure, such as size and location of lesions, the snare technique utilized, and any complications. If performed as a screening, documentation must support the medical necessity for a screening colonoscopy.
- Specialties:Gastroenterology, General Surgery, Colorectal Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office