According to the National Institutes of Health, digestive diseases affect an estimated 60 to 70 million people in the United States. Among the diagnostic procedures used to evaluate digestive diseases, colonoscopy is one of the most commonly performed.
But how is a diagnostic colonoscopy reported in medical billing?
One of the ways is to report CPT code 45378 on the professional claim form. Additionally, certain circumstances require the use of a modifier for accurate claim reporting and reimbursement.
45378 might seem straightforward, but its billing can be complex. Fortunately, we cover the following in this guide:
- Relevant scenarios
- Applicable modifiers
- Reimbursement guidelines for cleaner claims
CPT Code 45378 – Description
According to the American Medical Association (AMA) CPT codebook, as referenced by AAPC, CPT code 45378 is used to report:
“Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).”
This descriptor contains two key requirements that determine when CPT 45378 is appropriate.
- The procedure must be diagnostic in nature, with the colonoscope advanced through the colon for visual examination. It should not involve additional procedures such as:
- Biopsy collection
- Polyp removal (polypectomy)
- Other therapeutic interventions
- The phrase within the descriptor, “including collection of specimen(s) by brushing or washing, when performed,” indicates that brushings and washings do not require a separate charge, nor do they elevate the code. Simply put, they are bundled within CPT code 45378.
Appropriate Use Cases for CPT Code 45378
Accurate use of CPT 45378 requires understanding its appropriate clinical applications. Therefore, below are three comprehensive use cases with unique scenarios connected to 45378.
Symptomatic Diagnostic Colonoscopy, No Findings
Consider a 56-year-old male patient who presents to a gastroenterologist for evaluation. The patient has a documented history of intermittent rectal bleeding and bowel habit changes. The scope advances from the rectum to the cecum, and the patient’s colon is examined.
No abnormalities are identified during the procedure, and no specimen is collected. Since the procedure was diagnostic and not therapeutic, it is reported with CPT code 45378.
Incomplete Colonoscopy Due to Blood Pressure Drop
Say a gastroenterologist performs a diagnostic colonoscopy on a 72-year-old male patient referred for evaluation.
The patient is suspected of having iron deficiency anemia. However, during the procedure, the patient experiences a sudden drop in blood pressure.
The gastroenterologist determines that it is unsafe to continue the procedure and withdraws the scope. Since the cecum was not reached during the procedure, it is an incomplete colonoscopy.
Following CMS guidance, CPT code 45378 and modifier 53 can be used to report an incomplete colonoscopy in this case, as it was discontinued due to the patient’s worsening health.
Diagnostic Colonoscopy for Evaluation of Abdominal Pain
A 66-year-old female patient appeared at the gastroenterologist’s clinic for evaluation. She had been experiencing persistent lower abdominal pain for the past 90 days, limiting her daily life activities.
The patient also experienced bowel habit changes and shared details with the gastroenterologist.
To understand the reason behind these symptoms, a diagnostic colonoscopy was performed.
During the evaluation, the colonoscope was advanced all the way to the cecum, but no polyps, masses, or lesions were detected.
Additionally, specimens were collected via irrigation and aspiration, and CPT code 45378 was reported.
Modifiers to Append with CPT Code 45378
Modifiers directly affect claim processing and reimbursement. The following table outlines modifiers that may be appended to CPT code 45378 when supported by documentation.
| Modifier | Description | When to Use with CPT 45378 |
|---|---|---|
| 22 | Increased Procedural Services | Used when the provider wants to indicate that a substantially greater physician effort was required. |
| 52 | Reduced Procedure | Used when the colonoscopy was reduced or scaled back before the scope reached the cecum due to medical unnecessity. |
| 53 | Discontinued Procedure | Use when the colonoscopy is discontinued before reaching the cecum because of an unforeseen patient safety concern. |
Reimbursement Guidelines for CPT Code 45378
The reimbursement guidelines for 45378 are a foundation for accurate payments. Here are the essential guidelines to remember when billing for this CPT code:
Global Period
CPT code 45378 has a 0-day global period; any pre- and post-procedure visits are not included in the procedure payment.
However, an evaluation and management (E/M) service performed on the same day may be billed separately if identifiable and significant.
Note: Report modifier 25 on the E/M code, not on CPT 45378.
Reimbursement Considerations
Medicare reimbursement for CPT 45378 is based on the Medicare Physician Fee Schedule (MPFS) relative value units (RVUs). It varies by geographic locality and place of service (POS).
Payment rates differ between facility settings (such as ASCs and hospital outpatient departments) and non-facility settings (such as physician offices). Therefore, the locality rates should be verified before billing the insurer.
Bundling Rules
CPT code 45378 is included in all therapeutic colonoscopy codes (45379-45398). Therefore, it should not be billed separately within the same session. However, if a biopsy or other intervention is performed, only the definitive therapeutic colonoscopy code should be reported.
For example, if a biopsy is performed during the colonoscopy, report CPT 45380 instead of CPT 45378. If you bill both codes, it will be denied.
Coverage Criteria
Medicare covers diagnostic colonoscopy services when medically necessary and also covers screening colonoscopy services, subject to applicable coverage rules.
A screening colonoscopy is preventive and applicable to patients without any symptoms. Conversely, a diagnostic colonoscopy is done when a patient exhibits symptoms or abnormalities are discovered during screening.
Takeaway for CPT Code 45378
Getting the billing for CPT code 45378 right depends on several decisions before claim submission.
- Was the procedure therapeutic or diagnostic?
- Did the scope reach the cecum?
- Is a modifier required?
- Is the payer Medicare or commercial?
However, accurately answering these questions may be challenging for your in-house billing teams. Fortunately, NeuraBill’s gastroenterology billing services effectively handle the complexity of GI claim submission.
