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A flexible colonoscopy is a diagnostic and therapeutic procedure that involves the insertion of a colonoscope into the rectum and advancement through the colon to the cecum or the terminal ileum. This procedure is performed to visualize the mucosal surfaces of the colon, allowing for the inspection of any abnormalities such as tumors, polyps, or other lesions. During the colonoscopy, air insufflation is utilized to separate the mucosal folds, enhancing visibility for the physician. When a lesion is identified, the procedure can involve the removal of the lesion using hot biopsy forceps, which is specifically indicated by CPT® Code 45384. The hot biopsy technique employs insulated monopolar forceps that not only excise the tissue but also cauterize it simultaneously, making it particularly effective for small polyps and vascular ectasias. This method contrasts with the snare technique described in CPT® Code 45385, where a wire snare loop is used to remove larger lesions. After the removal of the lesion, the endoscope is withdrawn, and the mucosal surfaces are re-examined for any signs of complications such as ulcerations or bleeding.
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The procedure is indicated for the following conditions:
The procedure begins with the patient being positioned appropriately for the colonoscopy. The colonoscope, a flexible tube equipped with a camera and light source, is then inserted into the rectum. The physician carefully advances the colonoscope through the colon, reaching the cecum or the terminal ileum. During this advancement, air is insufflated into the colon to expand the lumen, allowing for better visualization of the mucosal surfaces. The physician inspects the colon for any abnormalities, such as tumors, polyps, or lesions. Once a lesion is identified, the hot biopsy forceps are introduced through the colonoscope. These specialized forceps are designed to grasp the lesion and simultaneously remove it while applying electrocoagulation to cauterize the tissue, minimizing bleeding. This technique is particularly effective for small polyps and vascular ectasias. After the lesion is excised, the colonoscope is withdrawn, and the physician conducts a thorough inspection of the mucosal surfaces once more to check for any signs of ulcerations, bleeding sites, strictures, or other abnormalities that may require further intervention.
Post-procedure care involves monitoring the patient for any immediate complications such as bleeding or perforation. Patients are typically advised to rest and may experience some discomfort or cramping following the procedure. It is important for the physician to provide specific instructions regarding dietary restrictions and activity levels after the colonoscopy. Follow-up appointments may be scheduled to discuss the results of the procedure and any further treatment options if necessary. Patients should be informed to report any unusual symptoms, such as severe abdominal pain or rectal bleeding, to their healthcare provider promptly.
| Short Descr | COLONOSCOPY W/LESION REMOVAL | Medium Descr | COLSC FLX W/REMOVAL LESION BY HOT BX FORCEPS | Long Descr | Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Endoscopic Base Code | 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8D - Endoscopy - colonoscopy | MUE | 1 | CCS Clinical Classification | 76 - Colonoscopy and biopsy |
| PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | SG | Ambulatory surgical center (asc) facility service | AG | Primary physician | GA | Waiver of liability statement issued as required by payer policy, individual case | RT | Right side (used to identify procedures performed on the right side of the body) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | LT | Left side (used to identify procedures performed on the left side of the body) | KX | Requirements specified in the medical policy have been met | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 33 | Preventive services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a us preventive services task force a or b rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. for separately reported services specifically identified as preventive, the modifier should not be used. | 47 | Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | FS | Split (or shared) evaluation and management visit | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary | KC | Replacement of special power wheelchair interface | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | SU | Procedure performed in physician's office (to denote use of facility and equipment) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter |
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| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 2015-01-01 | Changed | Description Changed |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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