Medicare CPT Code 45380 Description

CPT 45380

45380 Colonoscopy, flexible; with biopsy, single or multiple

45380 With biopsy, single or multiple

Multiple Endoscopy Reduction

Standard multiple procedure reduction adjustment rules are used to calculate reimbursement for endoscopic procedures within the same family

 Endoscopic procedures are ranked in descending order based on the appropriate facility or nonfacility RVU. If two or more procedures are of equal value, rank them in descending dollar order billed and base payment adjustments as if the second procedure has a lesser RVU value.

 If the endoscopy and its base procedure are the only endoscopies submitted, the base endoscopy  will not be reimbursed separately. It is included in the other procedure. 

In the MPFSDB these procedures are identified in the multiple procedure field with an indicator 3 and the base procedure code is located in the endo base column. Examples of procedures with a multiple procedure indicator 3 are colonoscopies, arthroscopies, and cystoscopies.

Multiple Endoscopy Example (Same Family) Determine the highest valued endoscopic procedure (not subject to the multiple endoscopy rule) For the other endoscopic procedures in the same family, apply the standard multiple procedure reduction

EXAMPLE

In the course of performing a fiber optic colonoscopy (Current Procedural Terminology (CPT®)1 code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. 

The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. 

When multiple procedures 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).

In this example, 45385 is reported without a modifier 51 and is not subject to an adjustment, Code 45380 is subject to adjustment. Append modifier 59 to 45380 to indicate that the polyp removal and lesion removal were at separate site and both should be considered.

45380 – 51 - 59 Subject to adjustment

NOTE: If an endoscopic procedure with an indicator of “3” is billed with the “-51” modifier with other procedures that are not endoscopies (procedures with an indicator of “1”), the standard multiple procedure reduction rules apply. (Refer to the Multiple procedure reduction rule for more information)

• Primary coding, CPT 45380 represents a colonoscopy with biopsy, CPT 45385 represents a colonoscopy with snare polypectomy

• Modified coding, CPT 45380-XS, CPT 45385

– The modifier -XS (separate structure) clarifies that the biopsy was of a different site than the snare polypectomy

As with any coding, modifiers should be used only when the medical record documentation clearly supports them. This is especially important because modifiers often affect the CPT/HCPCS code level of reimbursement.

As illustrated above, modifiers are two-digit codes that are categorized into two levels:

• Level I modifiers are numeric CPT modifiers maintained by the American Medical Association

• Level II modifiers are alphanumeric HCPCS modifiers maintained by the Centers for Medicare & Medicaid Services (CMS)

Colonoscopy 

Colonoscopies performed proximal to the splenic flexure (CPT codes 45380, 45383, 45384, and 45385) are considered part of the same family of endoscopic procedures. 

The biopsy of one or more lesions, as described in CPT code 45380, is considered integral to the more clinically intense multiple lesion removal and will not be separately reimbursed. 

Modifier 59 Exception Scenario: 

In the event that a biopsy of a lesion (CPT code 45380) is performed on a separate and distinct lesion from the lesion removal, you should append Modifier 59 to CPT code 45380.

In the event that a separate and distinct lesion(s) is removed via different surgical techniques such as with a snare or hot biopsy forceps, you should append Modifier 59 to CPT codes 45384 or 45385 as appropriate.

Question:

When billing a screening colonoscopy for a high risk Medicare patient, what code should I use to report the procedure? Should I use G0105 or 45380?

Answer:

When reporting a screening colonoscopy for a high risk Medicare patient, you should report it with the appropriate G code, namely, G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). You should also report the appropriate diagnosis code to support your claim for G0105. 

For instance if the patient previously had surgery for a colon cancer you would report the V code, V10.05 (Personal history of malignant neoplasm of large intestine) as the primary diagnosis.

If the patient was not a Medicare patient and you were reporting the screening colonoscopy to a commercial carrier, you would use the CPT® code 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]) for the procedure. 

In this case, you have to use the modifier 33 (Preventive services) to let the payer know that the service was a screening. Again, you have to report the appropriate diagnosis code such as V10.5 to support the service that was provided.

During the screening colonoscopy, if your clinician found polyps that he biopsied, then you do not report the procedure with G0105 or 45378. In such a case, where the screening turns diagnostic, you will have to use the appropriate therapeutic CPT® code instead of the G code. 

Since your clinician biopsied the lesions, you will then report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to report the procedure performed.

Don’t forget: Remember to attach 211.3 (Benign neoplasm of other parts of digestive system; colon) to 45380 to represent the patient’s polyps and to support the claim for 45380. You will append the modifier 33 (Preventive services) to let the payer know that the service was initiated as a screening.

Base Reduced Service Code on Original Intent

Question:

My doctor did an incomplete colonoscopy and I’m not sure how to code it. See following which are findings from his report: A fungating circumferential bleeding mass of malignant appearance was found in the proximal rectum and distal sigmoid colon at 15 cm from the anus.

The mass caused a partial obstruction. The scope could not traverse the lesion and the exam could not be finished. Cold forceps biopsies were performed. 4 1 ml india ink injections were successfully applied for tattooing. 

He coded colon w/biopsy and colon w/tattoo injection but I’m not sure if that’s correct. Can I bill both with incomplete modifier or should I bill flexible sigmoidoscopy with biopsy and injection?

Answer:

You will have to report the procedure on what the original intention of your clinician was. If he intended to perform a colonoscopy and was unable to complete it, then you report the appropriate colonoscopy codes with modifiers attached to it.

Since your clinician performed biopsy and tattooing of the mass, your clinician would be right in the way he reported the procedures. You should report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for the biopsy and 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), anysubstance) for the tattooing procedure performed. 

Append the modifier 52 (Reduced services) to these CPT® codes to let the payer know that your clinician intended to perform a colonoscopy but could not do so because the mass caused obstruction that did not allow further passage of the scope.

Q: Can we bill a 45380 with a 45385?

A: From a coding standpoint, if the same lesion is biopsied (45380) and removed (45385) at the same session, then only the removal should be reported. If the services are performed on two different lesions, then both services can be reported. 

In this instance you should attach the -59 modifier (distinct procedural service) on the biopsy code (45380) to indicate the services were performed on distinct lesions. It may be necessary to appeal with documentation. Make sure the procedure note clearly indicates that two lesions were involved.

Q: How should screening colonoscopies be appropriately billed where a polyp is excised and tested as benign?

The situation complicates payments when the patient believes that screening procedures are covered by their insurer at a different rate than nonscreening procedures and will be occurring more frequently as patients assume more of a share of payments to physicians and hospitals.

A: Medicare guidelines state that if at the time of a screening colonoscopy a lesion is biopsied or removed, the screening code (G0121) and the screening ICD-9 code (V76.51) should not be reported. Instead, you should report the appropriate CPT code (likely 45380) and the ICD-9 code (likely 211.3). 

For other payers, you report the appropriate CPT code for the procedure performed. You may elect to report both the V76.51 and the ICD-9 code for the polyp.