Colonoscopy is one of the most common gastroenterology procedures used to diagnose and manage issues related to the colon and rectum. Billing a straightforward colonoscopy procedure may be easier. But sometimes physicians need to perform a biopsy during that colonoscopy, which changes the billing entirely.
This procedure is billed with the CPT code 45380. Hence, billers or gastrointestinal (GI) specialists must understand how to bill this code to prevent costly denials.
In this guide, we break down everything you need to know about the 45380 CPT code, from its official description and appropriate use cases to the right modifiers, reimbursement rates, and the most common billing pitfalls to avoid.
CPT Code 45380 – Description
CPT code 45380 is maintained by the American Medical Association (AMA) as a part of the “Endoscopy Procedures on the Rectum” code range. It is officially defined as:
“Colonoscopy, flexible; with biopsy, single or multiple.”
Briefly, this code covers a flexible colonoscopy during which one or more tissue samples are collected from suspicious areas within the colon or rectum using biopsy forceps.
The procedure begins with the introduction of a colonoscope, equipped with a camera and light source, through the anus to visualize the mucosal lining. The medical professional then uses biopsy forceps to take a tissue sample. After collecting tissue specimens, the scope is removed, and the sample is sent to a pathology lab for additional examination.
Appropriate Use Cases for CPT Code 45380
CPT code 45380 is billed every time a diagnostic colonoscopy includes tissue sample collection. The following are some real-life scenarios that explain the application of this code.
Suspicion of a Colon Polyp
Suppose a 65-year-old patient undergoes a colonoscopy after experiencing bowel discomfort. During the procedure, the gastroenterologist identifies a small polyp in the descending colon. He decides to take a few tissue samples (using biopsy forceps) instead of removing the entire lesion. The sample is then sent to the pathology department to determine whether the growth is benign or malignant.
In this case, CPT code 45380 is an appropriate code to bill because the colonoscopy included a biopsy.
Chronic Diarrhea
Take an example of a 52-year-old patient who has suffered from persistent diarrhea for several months. He tried various medications and dietary modifications, but nothing actually worked.
The physician performs a colonoscopy to investigate possible inflammatory bowel disease. During the procedure, he decides to take multiple tissue samples, using biopsy forceps, from various sections of the colon.
This service will also be billed with the CPT code 45380 because multiple biopsies were obtained during the same procedure.
Rectal Bleeding
Imagine a 28-year-old patient visiting a physician with a complaint of bright red blood in his stool. The physician decides to conduct a colonoscopy, during which he identifies abnormal tissue in the colon and uses biopsy forceps to obtain biopsy specimens for diagnosing Crohn’s disease or colorectal cancer.
CPT code 45380 is the proper code because the procedure involves tissue sample collection for diagnostic purposes.
Modifiers to Append with CPT Code 45380
The following are some modifiers that may be appended to the CPT code 45380.
Modifier 33
Modifier 33 is used when a preventive screening colonoscopy is converted to CPT 45380 due to biopsy of an abnormality. Basically, 33 indicates that the service is preventive and has a U.S. Preventive Services Task Force (USPSTF) A or B rating. Adding this modifier means patients pay zero out-of-pocket costs like copays or deductibles.
Modifier 59
Modifier 59 is applicable when CPT code 45380 is billed with another distinct endoscopic procedure performed on the same date on the same patient.
Modifier PT
Modifier PT is applied to CPT 45380 when a screening colonoscopy is converted into a diagnostic or therapeutic procedure due to the discovery of abnormalities.
Reimbursement Guidelines for CPT Code 45380
By maintaining accurate paperwork and complying with the payer’s specific policies, you can easily bill the CPT code 45380 without risking claim denials. Here is how you can do this:
Unit Reporting
CPT 45380 covers one or more biopsies during a single colonoscopy session. So, you must report it once, regardless of how many biopsies or how many segments were sampled.
Documentation
To prove the medical necessity of the procedure, you must include the following information in the supporting documents for 45380:
- Patient history and indications for the procedure
- Information on unusual findings during a colonoscopy
- Exact anatomical locations of biopsies
- Number and type of specimens collected
- Physician’s procedure report
- Pathology submission details
- Date of service
Payer’s Policies
The billing criteria for a flexible colonoscopy with biopsy may differ from payer to payer. Commercial payers may differ in their billing policies and reimbursement rates for CPT code 45380. For example, some payers follow Medicare’s bundling and documentation rules, while some don’t.
Therefore, before filing a claim, we advise you to become familiar with the policies of the relevant payer.
Final Thoughts
Now is the time to conclude, but let’s take a moment to review all we learned.
CPT code 45380 is used to bill a flexible colonoscopy with a biopsy. Our examples of real-life scenarios further explained the applications of this code. We further discussed some applicable modifiers, such as PT, 33, and 59, that may be applied to 45380. Lastly, we highlighted some billing and reimbursement rules.
All of these instructions should help you bill 45380 correctly. However, you can opt for expert gastroenterology billing services from NeuraBill rather than struggling with the complexities of medical billing. Our gastrointestinal billing team is skilled and well-versed in payer-specific rules.
