2025 CPT code 45335
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance.
Modifiers may be applicable to 45335.For instance, modifier 53 may be used if the procedure is discontinued. Modifier 22 may be reported to indicate increased procedural services.
Medical necessity for 45335 depends on the specific clinical scenario.Examples of medically necessary scenarios include injection of sclerosing agents for hemorrhoids, marking lesions with dye for future surgical removal, and facilitating removal of difficult-to-access lesions by injecting saline.The medical record must document the clinical indication justifying the submucosal injection.
The physician performs a flexible sigmoidoscopy, visualizing the rectum and sigmoid colon.Through the scope, they administer one or more directed injections into the submucosal layer of the colon wall. The injected substance varies depending on the clinical indication.
In simple words: A flexible tube with a camera is inserted into the rectum and lower part of the colon. The doctor then injects a substance, such as medication or dye, into the lining of the colon wall.
The provider inserts a flexible endoscope into the anus and advances it through the rectum and sigmoid colon.One or more directed submucosal injections of any substance are then administered.Substances injected may include, but are not limited to: botulinum toxin, steroids, India ink, or saline.
Example 1: A patient presents with internal hemorrhoids. During a flexible sigmoidoscopy, the physician injects sclerosing agent into the submucosa around the hemorrhoids to shrink them., A patient has a small polyp in their sigmoid colon.During a flexible sigmoidoscopy, the physician injects India ink at the base of the polyp to mark it for future surgical removal., A patient with a difficult-to-access lesion in the sigmoid colon undergoes a flexible sigmoidoscopy. The physician injects saline into the submucosal layer to lift the lesion, facilitating its removal during a later procedure.
Documentation should include details of the procedure, including the insertion and advancement of the flexible endoscope, identification of the anatomical location reached, description of the lesion(s), the substance(s) injected, the site of injection(s), and any complications encountered.The medical necessity for the submucosal injection(s) should also be clearly documented.
- Specialties:Gastroenterology, General Surgery, Colorectal Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Physician's Office