Did you know that colon polyps affect about 20% of adults overall and about 40% over the age of 50? Besides, it also impacts 6% of children.
These numbers make it clear that colon polyps are common, but they do not mean they are harmless, as most colon polyps can become cancerous.
Screening colonoscopy, such as the one covered under CPT code 45385, is a common procedure that gastroenterologists conduct to visualize and remove polyps, tumors, and other lesions.
This guide will cover everything you need to know about this procedural code, from its real-world clinical scenarios to applicable modifiers and billing guidelines. So, continue reading!
CPT Code 45385 – Description
CPT code 45385 covers the examination of the rectum and colon using a colonoscope, i.e., a long, thin, flexible tubular instrument with a light source and camera.
This procedural code also includes the removal of one or more polyps, tumors, or other lesions with a snare. For context, a snare is a wire loop that he passes around the base of the lesion and tightens it until the wire cuts through the lesion.
Appropriate Use Cases for CPT Code 45385
Let’s review a few real-world clinical scenarios where CPT 45385 applies.
Diagnostic Colonoscopy After a Positive FOBT
Picture a 55-year-old male patient whose at-home fecal occult blood test (FOBT) came back positive. Thus, he visits the clinic for a diagnostic colonoscopy.
The gastroenterologist introduces the flexible colonoscope and carefully advances it to the cecum. During the procedure, he visualizes a 7 mm flat, well-defined polyp in the ascending colon.
As a result, the provider passes a cold snare wire loop through the scope channel, maneuvers it around the base of the lesion, and tightens it to slice and excise the tissue. He then sends the sample for pathological review.
Here, CPT code 45385 applies.
Surveillance Colonoscopy with Removal of Multiple Polyps
Consider a 40-year-old female patient with a personal history of colon polyps. She visits the clinic for a scheduled surveillance colonoscopy.
During the procedure, the gastroenterologist discovers two distinct lesions: an 8 mm polyp in the transverse colon and a 5mm pedunculated polyp in the sigmoid colon.
The gastroenterologist uses a cold snare to excise both lesions cleanly at their bases and retrieves them.
Here, you should report the CPT code 45385 to bill for the colonoscopy with lesion removal.
Diagnostic Colonoscopy Following a Positive FIT
Imagine a 61-year-old male patient who undergoes a diagnostic colonoscopy due to a positive fecal immunochemical test (FIT).
The gastroenterologist notes a 12 mm flat polyp in the cecum and safely removes it using a hot snare technique.
Additionally, while moving down to the rectosigmoid junction, the gastroenterologist notes a tiny 3 mm dimpled lesion. Thus, he removes it using hot biopsy forceps.
CPT code 45385 applies here. However, for the removal of the small dimpled lesion, CPT 45384 must also be reported, and modifier 59 should be appended to the secondary procedure code.
Modifiers to Append with CPT Code 45385
Discussed below are some of the applicable modifiers for CPT 45385:
Modifier 22
Did the polyp removal during the colonoscopy require you to spend significantly more time, effort, or resources than traditionally required?
If yes, report CPT code 45385 with modifier 22. If documentation supports this modifier usage, you are reimbursed at a 20% to 25% higher rate.
But never use it only to get a higher payout, since it can trigger costly payer audits and tarnish your practice’s reputation.
Modifier 52
What happens if you were removing a polyp during a colonoscopy (represented by CPT code 45385) but could not advance the scope all the way to the cecum due to anatomical blockage or poor preparation?
You append modifier 52 to highlight to the insurance carrier that the procedure was reduced or partially completed.
Note that the reimbursement for colonoscopies billed with modifier 52 directly depends on how much of the procedure you completed, as documented in the operative report.
Modifier 59
Do you want to know what happens when you remove two polyps using two different techniques during the same session, as we described in the scenario ‘diagnostic colonoscopy following a positive FIT’?
You append modifier 59 to CPT code 45385. However, remember that this does not apply when the same technique is used for removing multiple polyps.
Modifier PT
There may be scenarios where the Medicare beneficiary’s screening colonoscopy converts into a diagnostic or therapeutic procedure. When this happens, do not forget to append the modifier PT to the diagnostic or therapeutic procedural code, e.g., CPT code 45385.
Reimbursement Guidelines for CPT Code 45385
The following are some of the essential billing guidelines for CPT 45385:
Demonstrate Medical Necessity
Establishing medical necessity for the colonoscopy covered under CPT code 45385 is an integral requirement set forth by all insurance carriers.
Here are some of the qualifying clinical indications:
- Clearly record the signs or symptoms that justify why you conducted the procedure. These may include a positive colorectal cancer screening test, such as a FIT, chronic diarrhea, and lower gastrointestinal bleeding.
- Use screening code Z12.11 as primary for average-risk screening that turns into a snare polypectomy. Conversely, use Z86.010 as the secondary or supporting diagnosis for patients with a known history of polyps.
- Once you receive the pathology report, the final claim should include the definitive diagnosis code, such as D12.6 (benign neoplasm of the colon) or K63.5 (polyp of the colon).
Fulfill Documentation Requirements
Do you want to steer clear of denials on your CPT code 45385 claim? Then ensure that your documentation is comprehensive and contains everything listed below:
- Mention that the colonoscope passed the splenic flexure and reached the cecum or the ileocolic anastomosis.
- Explicitly use the word ‘snare’. For instance, cold snare, hot snare, snare cautery, etc. If you vaguely document that you removed the polyp, payers may downcode the claim to a less reimbursable biopsy code, 45380, or may straight away deny reimbursement for upcoding.
- Document every polyp by its size, location, and individual removal method to support the use of modifiers, such as 59.
Comply with Payer-Specific Policies
Remember that billing guidelines and reimbursement rules may vary across insurance carriers and the state you practice in. Thus, make it a rule of thumb to cross-check the requirements before billing a colonoscopy (CPT code 45385) to prevent unnecessary denials and payment delays.
Final Thoughts on CPT Code 45385
To summarize, CPT code 45385 covers a screening colonoscopy that also involves the removal of one or more polyps, tumors, or other lesions. Some of the applicable modifiers for this procedural code include modifier 22 (increased service), modifier 52 (reduced service), modifier 59 (distinct service), and PT (screening procedure turns into diagnostic or therapeutic).
Hopefully, this guide will become your go-to resource for billing your future colonoscopy claims. However, if you still struggle, feel free to outsource gastroenterology billing services to professionals like NeuraBill.
