2025 CPT code 45315

Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique.

Refer to CPT guidelines for proper coding of rigid proctosigmoidoscopy with removal of lesions. Modifier 59 may be appropriate if this procedure is performed in conjunction with other procedures in the same area.

Modifiers may be applicable.Modifier 59 may be appropriate when distinct procedural services are performed. Consult current CPT guidelines for appropriate use of modifiers with 45315.

Medical necessity must be established for this procedure. It is typically justified by symptoms such as rectal bleeding, changes in bowel habits, or abnormal findings on other diagnostic tests.

The physician prepares the patient, administers anesthesia, inserts the proctosigmoidoscope, examines the area, and removes the lesions using the appropriate technique.They also manage any complications and provide post-procedure care.

In simple words: The doctor examines the inside of your anus, rectum, and lower part of your colon with a small, rigid scope. They remove any abnormal growths, like polyps, using tools like heated forceps, a hot wire loop (snare), or electric current (cautery).

This procedure involves examining the anus, rectum, and sigmoid colon using a rigid proctosigmoidoscope. Multiple tumors, polyps, or other lesions are removed using hot biopsy forceps, bipolar cautery, or a snare technique.

Example 1: A patient presents with multiple polyps in their sigmoid colon discovered during a screening sigmoidoscopy. The physician performs a rigid proctosigmoidoscopy and removes all identified polyps using a combination of hot biopsy forceps and snare technique., A patient has several small tumors in their rectum. The physician uses a rigid proctosigmoidoscope and bipolar cautery to remove the tumors during an outpatient procedure., During a routine proctosigmoidoscopy, the physician identifies multiple lesions of uncertain nature in the rectum and sigmoid colon. They use hot biopsy forceps to obtain tissue samples for pathological analysis and removes some of the smaller lesions completely using the same instrument.

Documentation should include the size, number, and location of lesions; the method(s) used for removal; any complications encountered; and the patient’s response to the procedure.

  • Revenue Code: P8C
  • Specialties:Gastroenterology, General Surgery, Colorectal Surgery
  • Place of Service:Office, Ambulatory Surgical Center, Outpatient Hospital
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