© Copyright 2025 American Medical Association. All rights reserved.
A flexible colonoscopy is a diagnostic procedure that involves the use of a flexible tube called a colonoscope, which is equipped with a camera and light source. This procedure allows for direct visualization of the inner lining of the colon and rectum. During the colonoscopy, the colonoscope is inserted into the rectum and carefully advanced through the entire colon to the cecum or the terminal ileum. Air insufflation is utilized to expand the colon, which helps to separate the mucosal folds and enhances visibility for the physician. As the colonoscope is withdrawn, the physician examines the entire circumference of the colon for any signs of disease, injury, or abnormalities. In conjunction with the colonoscopy, an endoscopic ultrasound examination is performed using an echoendoscope, which is a specialized type of endoscope that incorporates ultrasound technology. The echoendoscope is inserted into the rectum and advanced to visualize not only the colon but also adjacent structures, including the cecum and pericolonic areas. To improve the quality of the ultrasound images, a balloon covering the transducer housing is filled with water, facilitating acoustic coupling. Continuous ultrasound imaging allows for the assessment of lesions, masses, or areas of compression, as well as the evaluation of the walls of the colon and surrounding structures, such as lymph nodes. In the context of CPT® Code 45392, the echoendoscope is guided to a specific area of concern, such as a mass located outside the colon or within its muscular wall. The ultrasound imaging aids in identifying these lesions, which may be candidates for biopsy. A fine needle aspiration or biopsy catheter is then advanced through the biopsy channel of the echoendoscope to obtain tissue samples from the identified lesions or lymph nodes. Doppler imaging is utilized to ensure that there are no vascular structures obstructing the biopsy path. The needle is carefully advanced through the colon wall into the targeted area, and multiple passes may be made to secure adequate tissue specimens. Each specimen is subsequently sent to a laboratory for cytologic examination, allowing for further analysis and diagnosis.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 45392 is indicated for various clinical scenarios where detailed examination and biopsy of the colon and adjacent structures are necessary. The following conditions may warrant the performance of this procedure:
The procedure involves several critical steps to ensure thorough examination and accurate biopsy collection:
After the completion of the procedure, patients are typically monitored in a recovery area until the effects of sedation wear off. It is common for patients to experience mild discomfort or cramping following the procedure, which usually resolves quickly. Patients may be advised to avoid strenuous activities for a short period and to follow specific dietary recommendations. The physician will discuss the results of the procedure and any necessary follow-up care, including the timing for obtaining biopsy results and any further diagnostic or therapeutic interventions that may be required based on the findings.
| Short Descr | COLONOSCOPY W/ENDOSCOPIC FNB | Medium Descr | COLSC FLX W/US GUID NDL ASPIR/BX W/US RCTM ET AL | Long Descr | Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures | 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 |
| 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. | 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). | 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). | 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. | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 2015-01-01 | Changed | Description Changed |
| 2005-01-01 | Added | First appearance in code book in 2005. |
Get instant expert-level medical coding assistance.