2025 CPT code 45390
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Digestive System - Endoscopy Procedures on the Rectum Surgery Feed
Colonoscopy, flexible; with endoscopic mucosal resection.
Modifiers 51 (multiple procedures), 52 (reduced services), 53 (discontinued procedure), and others may be applicable depending on the circumstances of the procedure.
Medical necessity is established by clinical findings that warrant the performance of a colonoscopy, such as abnormal screening tests, symptoms suggestive of colorectal pathology, or surveillance in patients with a history of polyps or colorectal cancer. The need for EMR is determined by the presence of a suspicious lesion requiring complete removal and histopathological analysis.
The clinical responsibility involves preparing the patient, inserting and maneuvering the colonoscope, identifying and excising lesions, ensuring hemostasis, and removing the scope. Post-procedure care and follow-up are also part of the physician's responsibility.
- Surgery
- Surgical Procedures on the Digestive System > Surgical Procedures on the Colon and Rectum > Endoscopy Procedures on the Rectum
In simple words: The doctor uses a thin, flexible tube with a camera (colonoscope) to examine the large intestine (colon). If they find an abnormal area, they remove a small piece of the inner lining using the scope.
This CPT code encompasses a flexible colonoscopy procedure where mucosal tissue is excised using an endoscope.The procedure involves inserting a flexible colonoscope into the colon to examine for lesions. Once a lesion is identified, a submucosal injection is usually administered to elevate the lesion, facilitating its excision using a snare or similar device.In cases of deep lesions, the injection may be repeated.Following excision, hemostasis is ensured before removing the colonoscope.
Example 1: A 60-year-old male patient presents for a colonoscopy screening.During the procedure, a suspicious polyp is discovered in the sigmoid colon. The physician performs an endoscopic mucosal resection (EMR) to remove the polyp., A 55-year-old female patient with a history of inflammatory bowel disease undergoes a colonoscopy. Several areas of ulcerative colitis are observed, and one area is chosen for EMR to obtain tissue for histopathological examination to aid in diagnosis., A 70-year-old patient presents for a colonoscopy following a positive fecal occult blood test.A large, flat lesion is found in the ascending colon. The physician performs endoscopic mucosal resection (EMR) to remove the lesion, ensuring adequate margins to rule out malignancy.The resected specimen is sent to pathology for analysis.
* Detailed history and physical examination relevant to the procedure.* Indication for the colonoscopy and EMR (e.g., screening, diagnostic, therapeutic).* Description of the lesion(s) location, size, and appearance.* Documentation of the technique used for EMR (e.g., snare polypectomy).* Description of any complications or adverse events.* Pathology report confirming the nature of the excised tissue.* Post-procedure orders and patient instructions.
** Always refer to the most up-to-date CPT codebook and coding guidelines for accurate coding practices.This information is for guidance only and should not be considered a substitute for professional coding advice.
- Revenue Code: P8D (ENDOSCOPY - COLONOSCOPY)
- RVU: This information is not available in the provided source.Relative Value Units (RVUs) vary based on geographic location, payer, and other factors.Consult the appropriate fee schedule for accurate RVU data.
- Global Days: This information is not available in the provided source. The global period for this procedure would need to be determined based on local payer rules and guidelines.
- Payment Status: Active
- Modifier TC rule: This information is not available in the provided source. The application of a Technical Component (TC) modifier would depend on the specific circumstances and payer rules.
- Fee Schedule: Fee schedule data is not provided in the source and varies based on location and payer.
- Specialties:Gastroenterology, Colorectal Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)