Colonoscopy Coding Updates
New definition. Colonoscopy is the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. For screening or diagnostic colonoscopy, report 45378 with modifier 53 if unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances and provide appropriate documentation. For therapeutic examinations that do not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.
New definition. Colonoscopy is the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. For screening or diagnostic colonoscopy, report 45378 with modifier 53 if unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances and provide appropriate documentation. For therapeutic examinations that do not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.
| CPT CODE | Short Description | Summary of Changes |
| 45399 | Transabdominal colonoscopy via colotomy | Code 45355 has been deleted. Report with new code for unlisted colon procedure, 45399 |
| 45378 | Colonoscopy | Colonoscopy is the examination of the entire colon, from the rectum to the cecum or small-intestine anastomosis, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. |
| 45379 | Foreign body(s) removal | “Foreign body(s)” replaces “foreign body.” |
| 45380 | Biopsy | Not separately reportable with EMR code 45390 for the same lesion. |
| 45381 | Submucosal injection | Not separately reportable with EMR or control of bleeding described by 45382 and 45390 for the same lesion. |
| 45382 | Control of bleeding | “Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45381, 45398 for same lesion. |
| 45384 | Hot biopsy | Bipolar cautery was deleted as an example. |
| 45385 | Snare | Not separately reportable with endoscopic mucosal resection described by 45390 for the same lesion. |
| 45386 | Dilation | New language specifies use of transendoscopic balloon. Dilation of multiple strictures can be reported with the 59 modifier for each additional stricture dilated. Not separately reportable with ablation or stent placement described by 45388, 45389. Use 74360 if fluoroscopic guidance is performed. |
| 45388 | Ablation | Code 45383 has been deleted. New code 45388 includes balloon dilation, guide wire insertion and ablation. Not separately reportable with dilation code 45386 for the same lesion. |
| 45389 | Stent placement | Code 45387 has been deleted. New code 45389 includes pre- and post-dilation and guide wire passage. Not separately reportable with dilation code 45386. Use 74360 if fluoroscopic guidance is performed. |
| 45391 | Endoscopic ultrasound | Now specifies exam limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures. Report only once per session. Not separately reportable with EUS FNA code 45392 or radiologic ultrasound codes 76872, 76975. |
| 45392 | Endoscopic ultrasound with FNA | Now specifies exam limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures. Report only once per session. Not separately reportable with EUS code 45391 or radiologic ultrasound codes 76872, 76942, 76975. |
| 45390 | Endoscopic mucosal resection (EMR) | New code 45390 is not separately reportable with biopsy, submucosal injection, snare or band ligation described by 45380, 45381, 45385, 45398 for the same lesion. |
| 45393 | Decompression | New code 45393 for decompression for pathologic distention, such as volvulus or megacolon. Includes placement of decompression tube when performed. Report only once per session. |
| 45398 | Band ligation | New code 45398 is not separately reportable with control of bleeding code 45334 for the same lesion. Do not report in conjunction with EMR or hemorrhoidectomy described by 45390, 46221. Report control of active bleeding with band ligation with 45382. |