2025 CPT code 45381
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Colonoscopy with directed submucosal injection(s) of any substance.
Modifiers may apply based on the circumstances of the procedure, such as modifier 53 (discontinued procedure) if the colonoscopy is incomplete or modifier 52 (reduced services) if only part of the procedure is performed.
Medical necessity for this procedure would be established by documented symptoms related to a colonic condition that might benefit from submucosal injection (e.g., strictures, inflammation in Crohn's disease).The type of substance injected must be clinically appropriate to the patient's condition and must be supported by the physician's clinical judgment.The procedure should be performed in accordance with all applicable standards of care.
The clinical responsibility rests with a gastroenterologist or other qualified physician who is trained and experienced in performing colonoscopies and submucosal injections. This includes proper patient preparation, anesthesia administration (if needed), insertion and manipulation of the endoscope, performing the injections with precision and accuracy, and post-procedure care.The physician needs to document the type and amount of substance injected, the location of the injection(s), and any complications encountered during or after the procedure.
In simple words: A colonoscopy is performed using a thin, flexible tube with a camera and light to view the inside of the colon (large intestine). During the procedure, the doctor injects a medication or substance under the lining of the colon.This may be done to treat a medical condition, mark a location, or help with removing a lesion.
This CPT code describes a flexible colonoscopy procedure where the physician inserts a flexible endoscope into the anus and navigates it through the entire colon.The procedure includes the performance of one or more directed submucosal injections of any substance, typically using a needle-tipped catheter inserted through the endoscope. Examples of substances include botulinum toxin, steroids, India ink, and saline. The injection is performed in the submucosa (the tissue layer beneath the mucous membrane).The procedure may also include examination of the terminal ileum or small intestine proximal to an anastomosis.The code does not include separate reporting for bleeding control during the same operative session.
Example 1: A patient presents with recurrent episodes of severe constipation.Colonoscopy reveals multiple areas of stricture in the sigmoid colon. The physician performs a colonoscopy with submucosal injections of botulinum toxin to relax the sphincter muscles and alleviate the constipation., During a routine screening colonoscopy, a small polyp is found in the ascending colon. The physician performs a submucosal injection of India ink to mark the polyp for later surgical removal using a snare technique., A patient with Crohn's disease has multiple areas of inflammation in the colon. The physician performs a colonoscopy and injects steroids into the inflamed areas of the submucosa to reduce inflammation and improve symptoms.
Detailed documentation must include:
** This code should only be reported when submucosal injections are performed.If only a biopsy is performed, then code 45380 may be more appropriate.Ensure complete and accurate documentation to support the medical necessity and justify the use of this code.Always refer to the most up-to-date CPT coding guidelines and payer specific policies.
- Revenue Code: P8D (ENDOSCOPY - COLONOSCOPY)
- Payment Status: Active
- Modifier TC rule: TC modifier typically does not apply to this code as it refers to a complete procedure.
- Specialties:Gastroenterology, Surgery (Colorectal surgery)
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient and Outpatient)