2025 CPT code 45346
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Digestive System - Endoscopy Procedures on the Rectum Surgery Feed
Flexible sigmoidoscopy with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage when performed.
Modifiers may be applied as needed, for example, modifier 52 (reduced services) if the procedure was incomplete or modifier 53 (discontinued procedure) if the procedure was stopped due to unforeseen circumstances.
Medical necessity for this procedure is established when there is a clinical indication, such as abnormal findings on prior imaging studies (colonoscopy, CT colonography), rectal bleeding, symptoms suggestive of colorectal pathology or as part of a colorectal cancer surveillance program.The procedure must be deemed necessary by the physician.
The physician's responsibility includes pre-procedure preparation of the patient, insertion of the sigmoidoscope, visualization of the sigmoid colon, ablation of lesions, dilation if needed, and post-procedure care.
In simple words: The doctor uses a thin, flexible tube with a light and camera (sigmoidoscope) to look inside the lower part of the large intestine (sigmoid colon).If any abnormal growths (polyps, tumors, or other lesions) are found, they are removed or destroyed (ablation).The doctor might also widen the area (dilation) before or after removing the growth. A thin wire may help guide the instruments.
This procedure involves the use of a flexible sigmoidoscope to examine the sigmoid colon.The physician ablates any polyps, tumors, or other lesions found.Pre- and post-dilation, along with guide wire passage, may be included as needed. The procedure is performed after appropriate patient preparation and anesthesia. The sigmoidoscope is inserted into the anus and advanced to examine the rectum and sigmoid colon. Once a lesion is located, ablation is performed. Multiple lesions may be ablated during the same encounter. Dilation may be performed before, after, or both before and after ablation. A guide wire can be used to facilitate the procedure.After the ablation, the sigmoidoscope is removed.
Example 1: A patient presents with a suspicious polyp identified on a prior colonoscopy. A flexible sigmoidoscopy with ablation is performed to remove the polyp. Pathology is sent for analysis. , A patient experiences rectal bleeding.Flexible sigmoidoscopy with ablation is performed to identify and treat the source of bleeding, which is determined to be a small vascular lesion. , A patient has a known history of colon cancer and undergoes surveillance flexible sigmoidoscopy. During this procedure, a small, superficial, cancerous lesion is identified and ablated.
* Detailed history and physical examination documenting the indication for the procedure.* Documentation of the type and number of lesions ablated.* Documentation of any pre- and post-dilation performed.* Pathology report if tissue is removed.* Operative report detailing the procedure performed.* Anesthesia record.
** This code should only be used when ablation is performed.If a snare is used to remove the lesion(s), code 45338 is appropriate.
- Revenue Code: P8C (Endoscopy - Sigmoidoscopy)
- RVU: This information is not provided in the source.RVUs vary based on geographic location and payer.
- Global Days: This information is not provided in the source.Global surgical days are not applicable to this procedure.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not applicable to this code.
- Fee Schedule: This information is not available in the provided sources.
- Specialties:Gastroenterology, Colorectal Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center