2025 CPT code 45338
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Flexible sigmoidoscopy with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
Modifiers such as 22 (Increased Procedural Services), 52 (Reduced Services), and 53 (Discontinued Procedure) may be applicable in certain circumstances.
Medical necessity for 45338 must be supported by documentation of symptoms, positive findings on other diagnostic tests, or a history of conditions that warrant a sigmoidoscopy and removal of lesions.
The physician is responsible for preparing the patient, administering anesthesia (if necessary), inserting and maneuvering the sigmoidoscope, identifying and removing lesions using the snare technique, and ensuring proper documentation of the procedure.
In simple words: This procedure involves examining your rectum and lower part of your colon with a flexible tube that has a camera. If any abnormal growths (like polyps or tumors) are found, they are removed using a wire loop during the same procedure.
This code describes a procedure where a flexible sigmoidoscope (a thin, flexible tube with a camera) is inserted through the anus to examine the rectum and sigmoid colon. During the procedure, any tumors, polyps, or other lesions found are removed using a snare technique. This involves passing a wire loop over the growth and then severing it from the lining of the colon.
Example 1: A patient presents with rectal bleeding. A flexible sigmoidoscopy is performed, and a polyp is found in the sigmoid colon. The polyp is removed using a snare technique during the procedure. Code 45338 is reported., A patient is undergoing a routine screening flexible sigmoidoscopy. A small tumor is discovered in the rectum. The tumor is removed via snare polypectomy. Code 45338 is reported., A patient with a history of colon cancer is undergoing surveillance. During a flexible sigmoidoscopy, several polyps are identified and removed using a snare technique. Code 45338 is reported.
Documentation should include the size and location of the removed lesion(s), the snare technique used, any complications encountered, and the findings of the sigmoidoscopy.
- RVU: As of December 1, 2024, I am unable to retrieve the historical data and current RVUs based on the provided documents. For updated information on RVUs, please refer to the latest edition of the iFrameAI database for CPT codes.
- Specialties:Gastroenterology, General Surgery, Colorectal Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Physician's Office