2025 CPT code 45384
(Active) Effective Date: N/A Revision Date: N/A Surgery - Colonoscopy with lesion removal Digestive System Feed
Colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps.
Modifiers may be applied to this code as appropriate, such as modifier 52 for reduced services if the procedure was incomplete or terminated early, or modifier 53 for a discontinued procedure.Appropriate modifier usage is highly dependent on the circumstances and should reflect the services performed.
Medical necessity for colonoscopy with polypectomy is determined by the patient's symptoms, age, family history, and risk factors for colorectal cancer.Screening colonoscopies are typically performed in accordance with age and risk guidelines established by national organizations such as the American Cancer Society. Diagnostic colonoscopies are medically necessary when symptoms such as rectal bleeding, changes in bowel habits, or abdominal pain are present.Removal of polyps is medically necessary when there's a risk of cancer or significant bleeding.
The physician is responsible for inserting the colonoscope, navigating it through the colon and rectum, identifying and removing lesions using hot biopsy forceps, applying cautery as needed to control bleeding, and collecting specimens for pathology.Pre-operative preparation and post-operative care may be handled by other healthcare professionals.
In simple words: The doctor uses a thin, flexible tube with a camera (colonoscope) to examine the inside of the colon and rectum.If they find any abnormal growths (tumors or polyps), they remove them using a special instrument that also seals the area to stop bleeding.
This CPT code, 45384, represents a flexible colonoscopy procedure where the physician removes one or more tumors, polyps, or other lesions using hot biopsy forceps. The procedure involves inserting a colonoscope through the anus, advancing it to inspect the colon and rectum, and then using hot biopsy forceps to excise the lesions.Electrical cautery may be used to control bleeding.Removed tissue is sent for pathology.
Example 1: A 60-year-old patient undergoes a screening colonoscopy. During the procedure, a single polyp is identified in the sigmoid colon and removed using hot biopsy forceps. The pathologist confirms the polyp is benign., A 72-year-old patient presents with rectal bleeding.A colonoscopy reveals a large, pedunculated tumor in the rectum. The tumor is removed using hot biopsy forceps and sent for pathology, revealing it to be malignant. The patient is referred for further treatment., A 55-year-old patient has a history of inflammatory bowel disease (IBD).A colonoscopy shows multiple areas of inflammation with small polyps.Several polyps are removed using hot biopsy forceps. Pathology reveals mild dysplasia in some of the removed specimens.
* Pre-procedure patient consent form* Complete patient history and physical examination documentation* Indication for the procedure (screening, diagnostic, therapeutic)* Detailed operative report with description of procedure, findings, and lesions removed* Pathology report of removed specimens* Anesthesia record if applicable* Post-procedure instructions and follow-up plan
** Always refer to the most current CPT manual and payer guidelines for the most up-to-date coding and reimbursement information.Accurate coding requires detailed documentation of the procedure performed, including the number and location of lesions removed, technique used, and any complications encountered.
- Revenue Code: P8D (ENDOSCOPY - COLONOSCOPY)
- RVU: Information not available in provided sources.RVUs vary by payer and geographic location.
- Global Days: The global period for this procedure is not specified in the provided sources. Consult the specific payer's guidelines for details on the global period.
- Payment Status: Active
- Modifier TC rule: The application of a Technical Component (TC) modifier is dependent upon the specific circumstances of the procedure and billing practices of the provider and payer.If both a professional and technical component were provided by different individuals, a TC modifier may be appropriate.Always follow payer-specific rules.
- Fee Schedule: Information not available in provided sources. Fee schedules vary by payer and geographic location and change over time.Consult payer fee schedules for relevant information.
- Specialties:Gastroenterology, Colorectal Surgery, General Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)