2025 CPT code 45378
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Diagnostic colonoscopy, including specimen collection (if performed), using a flexible scope. This is a stand-alone procedure.
Modifiers may be applicable. Modifier 53 is used if the procedure is discontinued. Modifier 59 may be used to indicate a distinct procedural service.
Medical necessity for 45378 must be established based on symptoms, positive screening tests, or other clinical indicators. Justification for the procedure should be clearly documented.
The physician inserts a colonoscope through the anus, advances it through the colon, and inspects the lining. Specimens may be collected by brushing or washing, and sent to a laboratory for analysis.
In simple words: A doctor examines the colon and rectum with a flexible tube equipped with a camera. If any abnormal areas are found, small tissue samples may be taken for testing.
Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
Example 1: A patient presents with unexplained abdominal pain and altered bowel habits. A diagnostic colonoscopy (45378) is performed to evaluate the colon and rule out any underlying pathology., A patient has a positive fecal occult blood test. A diagnostic colonoscopy (45378) is performed to investigate the source of bleeding and look for any lesions., As part of a routine screening for colorectal cancer, a diagnostic colonoscopy (45378) is performed on an asymptomatic patient over the age of 50.
Documentation should include the indication for the procedure, the extent of the exam, any specimens obtained, and any complications encountered.
- Revenue Code: P8D
- Specialties:Gastroenterology
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, On Campus-Outpatient Hospital, and Off Campus-Outpatient Hospital