2025 CPT code 45340
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Flexible sigmoidoscopy with transendoscopic balloon dilation of one or more strictures.
Modifiers 52 (reduced services), 53 (discontinued procedure), and 59 (distinct procedural service) may be applicable depending on the circumstances of the procedure.Consult the CPT manual for appropriate modifier use.
Medical necessity for 45340 is established when a patient presents with symptoms consistent with colonic stricture, such as bowel obstruction, abdominal pain, or changes in bowel habits.Imaging studies (e.g., CT colonography, barium enema) may be used to confirm the presence and severity of the strictures prior to the procedure.The procedure is medically necessary to alleviate symptoms and improve bowel function.
The physician inserts the sigmoidoscope, examines the colon for strictures, introduces and inflates the balloon catheter to dilate the strictures, and removes the instruments.Appropriate pre-operative preparation and anesthesia are also part of the clinical responsibility.
In simple words: The doctor uses a thin, flexible tube with a camera to examine the rectum and part of the large intestine. If there are any narrowed areas, a small balloon is inflated to gently widen them.
This procedure involves the endoscopic examination of the rectum and sigmoid colon using a flexible sigmoidoscope.A balloon catheter is introduced through the sigmoidoscope's channel to dilate one or more strictures (abnormal narrowings) in the colon. The balloon is inflated at the stricture site to widen the narrowed lumen, then deflated and the process is repeated for each stricture.The procedure concludes with removal of the scope and catheter.
Example 1: A patient presents with symptoms of bowel obstruction and a sigmoidoscopy reveals multiple strictures in the sigmoid colon. The physician performs a transendoscopic balloon dilation of these strictures using code 45340., During a routine flexible sigmoidoscopy, a single stricture is identified. The physician uses the balloon dilation component of 45340 to widen the stricture, improving bowel transit., A patient with a history of inflammatory bowel disease undergoes a sigmoidoscopy which reveals two significant strictures obstructing fecal passage.The physician performs a transendoscopic balloon dilation of both strictures, reporting 45340 with modifier 59 for the second stricture.
Pre-procedure history and physical examination, including patient's symptoms, indication for the procedure, and relevant imaging studies if available.Detailed procedural notes outlining the location, number, and size of strictures, the balloon dilation technique used, and any complications encountered.Post-procedure assessment of the patient's condition and any follow-up plans.
** Accurate documentation is critical for proper coding and reimbursement.The number and location of strictures dilated should be clearly documented.Consult the latest CPT manual and NCCI edits for any updates or changes to coding guidelines.
- Revenue Code: P8I (ENDOSCOPY - OTHER)
- Payment Status: Active
- Modifier TC rule: This procedure does not typically require a technical component modifier.
- Specialties:Gastroenterology, Colorectal Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department