2025 CPT code 45398
Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Colonoscopy, flexible; with band ligation(s) (e.g., hemorrhoids)
Modifiers may be applicable. Refer to current CPT guidelines.
Medical necessity must be established for the colonoscopy and for the band ligation(s).This may include documentation of symptoms (e.g., bleeding, pain), presence of polyps or other lesions, or prophylactic intent based on the patient's medical history.
The physician is responsible for preparing the patient, administering anesthesia, performing the colonoscopy, identifying and isolating the target structures, applying the bands, and ensuring the procedure is completed safely and effectively.
In simple words: During a colonoscopy (examining the large intestine with a camera), the doctor places small rubber bands around hemorrhoids or similar structures to remove them. This cuts off their blood supply, causing them to shrink and fall off.
This code describes a procedure where the physician performs a flexible colonoscopy and ligates one or more structures, such as hemorrhoids, using bands.The patient is prepped and anesthetized, the colonoscope is introduced, the target structure (e.g. hemorrhoid) is identified and isolated, and a band is applied to cut off blood supply, causing it to eventually shed.Multiple band ligations may be performed during the same procedure. The code should not be reported in conjunction with 45382 for the same lesion, nor with 45378, 45390, or 46221. It should also not be reported more than once per session.
Example 1: A patient presents with symptomatic internal hemorrhoids. During a scheduled flexible colonoscopy, the physician identifies three internal hemorrhoids and performs band ligation on each of them., During a screening colonoscopy, a small polyp is discovered in the sigmoid colon.Due to its size and location, the physician decides to perform band ligation for removal during the same procedure., A patient with a history of rectal bleeding undergoes a flexible colonoscopy.While no active bleeding is found, several prominent vascular lesions are identified, and the physician performs band ligation as a preventative measure.
Documentation should include details of the colonoscopy findings, including size, location and number of structures ligated.The reason for ligation should also be documented, such as symptomatic hemorrhoids, polyp removal, or preventative treatment of vascular lesions.If other procedures are performed during the same session, this should be clearly documented as well.
- Revenue Code: P8D - ENDOSCOPY - COLONOSCOPY
- Specialties:Gastroenterology, General Surgery, Colorectal Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Office