2025 CPT code 45391
(Active) Effective Date: N/A Revision Date: N/A Surgery - Endoscopic Procedures Surgery Feed
Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 52 for reduced services, 53 for discontinued procedure).
Medical necessity for this procedure is established based on the patient's symptoms, medical history, and risk factors for colon cancer.Screening colonoscopy with EUS is indicated in individuals at high risk for the disease. Diagnostic EUS is used to assess lesions identified during colonoscopy, guiding management decisions.
The physician inserts a colonoscope, advances it to the cecum, inspects the lumen of the colon and rectum, introduces an ultrasound probe, performs an ultrasound examination, and removes the probe and scope.Appropriate pre-operative preparation and anesthesia are required.
In simple words: The doctor examines your colon using a thin, flexible tube with a camera and light (colonoscopy).They also use ultrasound through the tube to get detailed pictures, helping them diagnose problems like colon cancer.
This CPT code describes a flexible colonoscopy with endoscopic ultrasound (EUS) examination. The EUS examination is limited to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon, cecum, and adjacent structures.The procedure involves inserting a colonoscope through the anus and advancing it to the cecum. The provider inspects the colon and rectum, and then introduces an ultrasound probe through the scope to perform the EUS examination. This helps in diagnosing and staging colon cancer.
Example 1: A 60-year-old patient presents with symptoms suggestive of colon cancer. A flexible colonoscopy with EUS is performed to visualize the colon and obtain tissue samples for biopsy, allowing for accurate diagnosis and staging of the cancer., A 55-year-old patient undergoes a screening colonoscopy. During the procedure, a suspicious polyp is identified. EUS is used to determine the depth of invasion and assess the need for further interventions such as surgical resection., A 70-year-old patient with a history of colon cancer undergoes a follow-up colonoscopy.EUS is used to evaluate for recurrence and to guide any necessary therapeutic interventions such as ablation or stent placement.
* Pre-procedure patient history and physical examination findings.* Indication for the procedure (e.g., screening, diagnostic, therapeutic).* Detailed description of the endoscopic findings.* Results of the endoscopic ultrasound examination, including images and measurements.* Number and location of biopsies performed.* Any complications encountered during the procedure.* Post-procedure care instructions.
** This procedure may be performed with or without biopsy or other therapeutic interventions.Appropriate documentation must reflect the specific services performed.
- Revenue Code: P8D (ENDOSCOPY - COLONOSCOPY)
- Payment Status: Active
- Specialties:Gastroenterology, Colorectal Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital