CPT code 45378 (Colonoscopy) coding guide

Basics of CPT code 45378 (colonoscopy)

Colonoscopy is an examination of the entire colon, from the rectum to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis. Colonoscopy is the most effective diagnostic procedure for colon polyps and early colorectal cancer. CPT code 45378 is one of the procedure code used for reporting colonoscopy.

A flexible colonoscopy is performed with or without collection of specimens by brushing or washing. The colonoscope is inserted into the rectum and advanced through the colon to the cecum or a point within the terminal ileum, using air insufflation to separate the mucosal folds for better visualization. Mucosal surfaces of the colon are inspected and any abnormalities are noted.

The endoscope is then withdrawn as mucosal surfaces are again inspected for ulcerations, varices, bleeding sites, lesions, strictures, or other abnormalities. Cytology (cell) samples may be obtained using a brush introduced through the endoscope. Alternatively, sterile water may be introduced to wash the mucosal lining and the fluid aspirated to obtain cell samples. Cytology samples are sent for separately reportable laboratory analysis.

Description of CPT code 45378 (colonoscopy)

The 2023 Physician Fee Schedule rule released on 11/1/22 and as per the new update CMS is lowering the age for screening from 50 to 45. Patients can begin screening for colorectal cancer (CRC)at 45, without being charged a copay or deductible.

45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Screening Colonoscopy describes as it is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. A diagnostic test is done in response to a sign or symptom, to investigate and diagnosis a condition. A patient with rectal bleeding and anemia who is has a colonscopy is having a diagnostic colonoscopy.

An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

Do not report a colonoscopy procedure code for an endoscopy performed with a sigmoidoscope on a patient with a normal length colon, even if the sigmoidoscope reaches proximal to the splenic flexure. A sigmoidoscope (an endoscope typically 65 centimeters in length) may be used for a colonoscopy only if the bowel is sufficiently short so that the entire colon may be examined, and such should be clearly documented in the clinical record.

Coding tips for CPT code 45378 (colonoscopy)

Do not report with any surgical colonoscopy.
If for some reason the procedure is incomplete and the scope is not advanced to the splenic flexure, use a modifier to indicate a discontinued or reduced procedure. Do not report a sigmoidoscopy or proctosigmoidoscopy instead.
Avoid separate billing for control of bleeding when bleeding occurs as a result of the endoscopic procedure.
If the intent of the procedure was a screening and the patient is a Medicare patient, report G0105 or G0121 instead.

Additional Code Information for CPT code 45378 (colonoscopy)

PC/TC Indicator (26):0 = Physician Service Codes

Multiple Procedures (51):2 = Standard payment adjustment rules for multiple procedures apply

Bilateral Surgery (50):0 = 150% payment adjustment for bilateral procedures does not apply

Physician Supervision: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

Diagnostic Imaging Family:99 = Concept does not apply

RVUs and Fees for CPT code 45378 (colonoscopy)

Non-Facility	Work	MP	PE	RVU	Total
Non-Facility	3.26	0.42	6.51	10.19	$345.31
Facility	Work	MP	PE	RVU	Total
Facility	3.26	0.42	1.74	5.42	$183.67

RVUs and Fees with Modifier 53

Non-Facility	Work	MP	PE	RVU	Total
Non-Facility	1.63	0.21	3.25	5.09	$172.49
Facility	Work	MP	PE	RVU	Total
Facility	1.63	0.21	0.87	2.71	$91.83

Related CPT codes for colonoscopy

45379 Colonoscopy, flexible; with removal of foreign body(s)
45380 Colonoscopy, flexible; with biopsy, single or multiple
45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance
45382 Colonoscopy, flexible; with control of bleeding, any method
45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and postdilation and guide wire passage, when performed)
45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45386 Colonoscopy, flexible; with transendoscopic balloon dilation
45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre- and postdilation and guide wire passage, when performed)
45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures
45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needleaspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures
45390 Colonoscopy, flexible; with endoscopic mucosal resection
45393 Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including
placement of decompression tube, when performed
45398 Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema.
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0122 Colorectal cancer screening; barium enema
G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous

Clinical example 1

A 52-year-old patient calls the surgeon’s office and requests a screening colonoscopy. The patient has never had a screening colonoscopy. The patient has no history of polyps and none of the patient’s siblings, parents or children has a history of polyps or colon cancer. The patient is eligible for a screening colonoscopy. Reportable procedure and diagnoses include:

45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
Z12.11, Encounter for screening for malignant neoplasm of colon

Clinical example 2

The same 52- year-old patient from the previous example has had an abnormal finding during their screening colonoscopy. The surgeon removes a polyp with a snare technique. Reportable procedure and diagnoses include:

45385-33, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesions by snare technique
Z12.11, Encounter for screening for malignant neoplasm of colon
K63.5 Polyp of the colon

In this case, report Z12.11 as the primary diagnosis to indicate it was scheduled as a screening test and K63.5 as the secondary diagnosis. In addition, modifier 33 tells the payer that the primary purpose of the test was screening, in accordance with evidence based practice as identified by USPSTF.

Sample Coded report for CPT code 45378 (colonoscopy)

COLONOSCOPY REPORT

LOCATION: Cedar Lake Surgery Center

COLONOSCOPY: Diagnostic

LAST COLONOSCOPY: None
INDICATIONS: Change in bowel pattern, left-sided abdominal pain
MEDICATIONS: See anesthesia note
DESCRIPTION: The Colonoscopy was explained in detail to the patient prior to the procedure including risks such as bleeding and colonic perforation. The patient was informed that in the event of a complication, they may require surgery to treat the complication. The patient was brought to the endoscopy suite and placed in the left lateral decubitus position. On external anal exam, there was no evidence of external hemorrhoids or fissures. On digital rectal exam there was no palpable masses. A standard Olympus colonoscope was inserted into the rectum and passed in the usual fashion to the level of the terminal ileum. The preparation of the colon was excellent with a Boston bowel prep score of 9. The scope was then slowly withdrawn and careful examination of the entire colon was performed.

FINDINGS / THERAPY:
Ileum -normal
Cecum -normal
Ascending colon -normal
Hepatic flexure -normal
Transverse colon -normal
Splenic flexure -normal
Descending colon -normal
Sigmoid colon -patient has a lot of spasm in the sigmoid colon but there is no evidence of colitis or neoplastic disease
Rectum -normal
Anal canal -normal
***Withdrawal time 8 minutes