2025 CPT code 45309
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Digestive System - Endoscopy Surgery Feed
Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique.
Modifiers 52 (reduced services), 53 (discontinued procedure), and others may be applicable depending on the circumstances.Consult the current CPT guidelines and your payer's specific rules for modifier application.
Medical necessity would be established by the presence of a lesion requiring removal.Documentation should support the clinical indication for the procedure, such as symptomatic bleeding, imaging findings, or findings from a prior endoscopic examination.
The physician is responsible for performing the procedure, including bowel preparation assessment, insertion and manipulation of the rigid proctosigmoidoscope, visual inspection of the rectum and sigmoid colon, identification and removal of the lesion using snare technique, and post-procedure care instructions.
In simple words: The doctor examines the inside of the anus, rectum, and part of the large intestine using a special camera.A small growth or abnormal tissue is then removed using a thin wire loop.
This procedure involves the examination of the rectum and a portion of the sigmoid colon using a rigid proctosigmoidoscope.A single tumor, polyp, or other lesion is removed using a snare technique. The procedure includes insertion of the scope, inspection of the anal canal, rectum, and sigmoid colon, and removal of the identified lesion using a wire snare to excise or destroy the abnormal tissue. The scope is then withdrawn.
Example 1: A patient presents with a single polyp identified during a prior colonoscopy.The physician performs a rigid proctosigmoidoscopy and removes the polyp using snare technique., A patient reports rectal bleeding.A rigid proctosigmoidoscopy reveals a small, benign tumor. The physician removes the tumor using a snare., During a routine flexible sigmoidoscopy, a suspicious lesion is found in the rectum. The physician then uses a rigid sigmoidoscope to remove the lesion using a snare technique.
* Pre-procedure patient history and physical examination* Indication for the procedure (e.g., abnormal findings on prior imaging, symptomatic bleeding)* Detailed operative report including description of lesion, location, size, technique used for removal, and specimen handling* Pathology report of the removed tissue* Post-procedure patient assessment and instructions
** The information provided is based on the available data.Always refer to the most current CPT codebook and payer guidelines for accurate coding and billing practices.Specific details regarding anesthesia, use of other instruments, and post-operative care are not explicitly defined in provided information and would need to be considered based on the specifics of the actual procedure performed.
- Revenue Code: P8C (Endoscopy - Sigmoidoscopy)
- RVU: This information requires access to current fee schedules and RVU data which is not available in provided text.Consult a medical billing resource for the most current RVU values.
- Global Days : Global period information is not specified for this code in the provided text. Consult a current CPT codebook for guidance.
- Payment Status: Active
- Modifier TC rule: The provided text does not offer information on whether a technical component (TC) modifier applies. Consult the current CPT codebook for this information.
- Fee Schedule : Fee schedule data was not provided in source.Refer to a fee schedule database from your payer or a reputable medical billing resource.
- Specialties:Gastroenterology, Colorectal Surgery, General Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)