2025 CPT code 45331
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Flexible sigmoidoscopy with single or multiple biopsies.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., modifier 53 for a discontinued procedure, modifier 52 for reduced services).
Medical necessity is established by the presence of symptoms suggestive of colorectal pathology (e.g., rectal bleeding, change in bowel habits, abdominal pain) or as part of routine colorectal cancer screening based on age and risk factors.The procedure should be medically necessary and appropriate based on the patient's clinical presentation.
A gastroenterologist or other qualified physician performs this procedure.The physician inserts the sigmoidoscope, visualizes the colon, takes biopsies if needed, and interprets the findings. The procedure requires preparation and anesthesia, as appropriate.
In simple words: The doctor uses a thin, flexible tube with a camera to look inside the rectum and a part of the large intestine (sigmoid colon).Small tissue samples may be taken for testing.
This procedure involves the insertion of a flexible sigmoidoscope into the rectum and sigmoid colon to visualize the mucosal lining.Biopsies (single or multiple) are obtained for pathological examination. The procedure may include examination of a portion of the descending colon up to the splenic flexure.The scope is withdrawn once the examination and biopsy are complete.
Example 1: A patient presents with rectal bleeding.A flexible sigmoidoscopy with biopsy is performed to identify the source of bleeding and rule out malignancy. Multiple biopsies are taken from different areas of the sigmoid colon and rectum., A patient with a history of inflammatory bowel disease undergoes a routine flexible sigmoidoscopy with a single biopsy to monitor disease activity and assess inflammation., A patient presents with change in bowel habits. A flexible sigmoidoscopy with biopsy is performed to rule out colon polyps or cancer.Several biopsies are obtained for analysis.
* Complete patient history and physical examination.* Indication for the procedure (e.g., rectal bleeding, change in bowel habits, screening).* Description of the procedure performed (insertion of the sigmoidoscope, visualization of the colon, location and number of biopsies).* Pathological report of the biopsy specimens.* Post-procedure instructions to the patient.
** The depth of the examination and the number of biopsies taken will vary depending on the clinical indication.Appropriate documentation is crucial for accurate coding and reimbursement.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Gastroenterology, Colorectal Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center