2025 CPT code 45342
Effective Date: N/A Surgery > Surgical Procedures on the Digestive System Feed
Sigmoidoscopy, flexible; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s).
Modifiers may be applicable. For example, Modifier 53 would be used if the procedure was discontinued.Modifier 22 would be applied for increased procedural services.
Medical necessity for 45342 is established when a biopsy or tissue sample is required for diagnosing or staging a suspected abnormality of the lower gastrointestinal tract.
The physician prepares the patient, administers anesthesia if necessary, inserts the sigmoidoscope, examines the colon up to the splenic flexure, performs the ultrasound, obtains tissue samples via fine needle aspiration and/or biopsy, and removes the instruments.
In simple words: The doctor uses a thin, flexible tube with a camera and ultrasound to look inside the lower part of your colon. They can also use it to take a small tissue sample if needed.
This procedure involves examining the anus, rectum, and sigmoid colon using a flexible sigmoidoscope equipped with a camera.An ultrasound probe is introduced through the scope to guide fine needle aspiration or biopsy of abnormal tissue within or through the wall of the colon. The scope is advanced to the splenic flexure.The ultrasound images help locate the precise area for tissue sampling.
Example 1: A patient presents with rectal bleeding and a suspicious lesion is found during a flexible sigmoidoscopy.45342 is performed to obtain a tissue sample for diagnosis. , A patient with a history of Crohn's disease undergoes surveillance. A thickened area of the sigmoid colon is visualized during flexible sigmoidoscopy. Code 45342 is used to guide a biopsy to assess disease activity., A patient with a known rectal mass undergoes 45342 to determine the extent of the tumor and to obtain tissue for staging.
Documentation should include the indication for the procedure, the extent of the exam, the location and description of any lesions, the type of ultrasound guidance used, and the tissue samples obtained.
- Revenue Code: P8C - ENDOSCOPY - SIGMOIDOSCOPY
- Specialties:Gastroenterology, Colorectal Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office