CPT codes for colonoscopy

Overview of CPT codes for colonoscopy

CPT Code	Code Descriptor
45378	Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
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
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
45388	Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and postdilation and guide wire passage, when performed)
45389	Colonoscopy, flexible; with endoscopic stent placement (includes pre- and postdilation and guide wire passage, when performed)
45390	Colonoscopy, flexible; with endoscopic mucosal resection
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 needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures
45393	Colonoscopy, flexible; with decompression (for pathologic distention) (e.g., volvulus, megacolon), including placement of decompression tube, when performed
45398	Colonoscopy, flexible; with band ligation(s) (e.g., hemorrhoids)

Overview of Content:

HCPCS Codes for Colonoscopy

HCPCS Code	Code Descriptor
G0105	Colorectal cancer screening: colonoscopy for an individual at high risk
G0121	Colorectal cancer screening: colonoscopy for an individual not meeting criteria for high risk

Cpt code for colonoscopy screening - 45378

What is the CPT code for a screening colonoscopy for non-Medicare patients?

The CPT code for a screening colonoscopy for non-Medicare patients is 45378, which describes a flexible sigmoidoscopy, including specimen collection (if performed, such as brushings or washings), and colon decompression (if needed).

What are the HCPCS codes for screening colonoscopies for Medicare patients?

For Medicare patients, screening colonoscopies use HCPCS codes:

G0105 for colorectal cancer screening in individuals at high risk
G0121 for colorectal cancer screening on individuals not meeting high-risk criteria

What if a screening colonoscopy becomes a therapeutic procedure?

If a screening colonoscopy turns therapeutic (e.g., polyp removal), the appropriate diagnostic or therapeutic CPT code (in the range 45379–45392) is reported instead of the screening codes.

Modifier PT is used to indicate procedures that were initially scheduled as screenings but were converted to diagnostic or therapeutic procedures.

What are the common ICD-10 codes for colonoscopy screenings?

Common ICD-10 screening diagnosis codes include:

Z12.11 – Screening for malignant neoplasm of the colon
Relevant family or personal history codes may accompany the screening code.

CPT code for colonoscopy with biopsy - 45380

What is the CPT code for a colonoscopy with biopsy?

The CPT code for a colonoscopy with biopsy (single or multiple) is 45380. This code specifically covers a flexible colonoscopy procedure in which tissue samples are taken for further examination. It is used when biopsies are performed during the colonoscopy to diagnose conditions such as colorectal cancer, polyps, or inflammatory bowel disease (IBD).

What is the CPT code for a diagnostic colonoscopy without biopsy?

45378 – Diagnostic colonoscopy, including specimen collection by brushing or washing (without biopsy).

What is the CPT code for colonoscopy with hot biopsy forceps?

45384 – Colonoscopy with removal of tumors or polyps by hot biopsy forceps (different from simple biopsy).

What is the CPT code for colonoscopy with snare technique?

45385 – Colonoscopy with removal of tumors or polyps by snare technique.

When should modifiers be applied to colonoscopy CPT codes?

Modifiers may be required depending on the procedure context, such as when a screening colonoscopy becomes diagnostic or therapeutic. In such cases, the appropriate CPT code is reported, and modifiers (e.g., PT) are used to clarify the clinical situation.

CPT code for colonoscopy with polypectomy - 45385,45384,45380,44392,44394

What is the primary CPT code for colonoscopy with polypectomy?

The primary CPT code for colonoscopy with polypectomy is:

45385 – Colonoscopy, flexible, with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.

What other CPT codes apply for polypectomy based on technique?

Other related codes include:

45384 – Colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.
45380 – Colonoscopy with biopsy, single or multiple (used for cold biopsy forceps).

What are the CPT codes for colonoscopy through a stoma with polyp removal?

Codes for colonoscopy through a stoma include:

44392 – Colonoscopy through stoma with removal by hot biopsy forceps.
44394 – Colonoscopy through stoma with removal by snare technique.

When should Modifier 33 be used?

Modifier 33 should be appended if the polypectomy is part of a preventive screening exam. This indicates that the procedure was performed for preventive services.

What ICD-10 codes are linked to colonoscopy with polypectomy?

Appropriate ICD-10 codes should be used to support medical necessity, including:

Screening codes (e.g., Z12.11 – Screening for malignant neoplasm of colon)
Benign neoplasm codes, depending on findings.

CPT code for colonoscopy with hot snare polypectomy - 45385

What is the CPT code for a colonoscopy with hot snare polypectomy?

The CPT code is 45385 – Colonoscopy, flexible, with removal of tumor(s), polyp(s), or other lesions using the snare technique. This includes both hot (electrocautery) and cold snare methods.

How does the hot snare technique work?

The hot snare technique uses a wire loop around the polyp, which is heated to cut and cauterize the polyp during removal.

Is CPT 45385 used for all snare techniques?

Yes. CPT 45385 is used regardless of whether the snare technique is hot snare, cold snare, monopolar, or bipolar.

When should Modifier PT be applied?

Modifier PT is recommended for Medicare patients to indicate that the procedure was initially a screening colonoscopy but converted to a therapeutic procedure.

What documentation is required for CPT 45385?

Documentation should include:

Details about the polyp(s)
The snare technique used
Removal details to support medical necessity

How is CPT 45385 different from biopsy removal codes?

45380 – Colonoscopy with biopsy forceps removal (cold biopsy)
45384 – Colonoscopy with hot biopsy forceps removal
CPT 45385 is specifically for snare polypectomy, not forceps removal.

CPT code for a colonoscopy with cold snare polypectomy

What is the CPT code for a colonoscopy with cold snare polypectomy?

The CPT code is 45385 – Colonoscopy, flexible, with removal of one or more polyps, tumors, or lesions using the snare technique.

Does CPT 45385 apply to both cold and hot snare methods?

Yes. CPT 45385 is used for both cold snare and hot snare techniques, as well as monopolar or bipolar snare procedures.

When is the cold snare technique typically used?

The cold snare technique is often used for diminutive polyps (smaller than 5 mm).

When is the hot snare technique typically used?

The hot snare technique is generally used for larger lesions, where cauterization is needed during polyp removal.

CPT code for colonoscopy through stoma - 44388

What is the CPT code for a colonoscopy through a stoma?

The primary CPT code is 44388 – Colonoscopy through a stoma, diagnostic. This code covers examination of the colon from the colostomy stoma to the cecum or colon-small intestine anastomosis, and may include the terminal ileum or small intestine proximal to an anastomosis.

What CPT codes apply if a biopsy is performed through a stoma?

44389 – Colonoscopy through stoma with biopsy, single or multiple.

What CPT codes apply if a lesion or polyp removal is performed through a stoma?

44392 – Removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.
44394 – Removal of tumor(s), polyp(s), or other lesion(s) by snare technique.

Which code should be used for a diagnostic or screening colonoscopy through a stoma?

44388 is appropriate for procedures that are diagnostic or screening only.

Which code should be used for therapeutic colonoscopy through a stoma?

Select the corresponding code (44389, 44392, or 44394) based on the specific intervention performed, such as biopsy or polyp removal.

CPT code for colonoscopy with control of bleeding - 45382

The CPT code for colonoscopy with control of bleeding is 45382. This code covers a flexible colonoscopy procedure performed to control bleeding in the colon by any method. It indicates that the physician examines and actively manages bleeding during the colonoscopy.

Important notes about CPT 45382:

It is used when treatment is required to control spontaneous or traumatic bleeding during colonoscopy.
Control of bleeding caused iatrogenically (by another intervention such as biopsy) is considered part of that procedure and not separately billable.
Modifiers such as -78 may be applicable if there is an unplanned return to the procedure room for bleeding control.

CPT code for colonoscopy with hemorrhoid banding - 45398

What is the CPT code for colonoscopy with hemorrhoid banding?

The correct CPT code is 45398 – Colonoscopy, flexible; with band ligation(s) (e.g., for hemorrhoids). This code is used when hemorrhoid banding is performed through the colonoscope during a flexible colonoscopy.

When should a different code be used for hemorrhoid banding?

If hemorrhoid banding is performed with a rigid scope or anoscope as a separate procedure, use:

46221 – Hemorrhoidectomy by rubber band ligation.

When is CPT 45398 appropriate?

45398 is used only when banding is part of the colonoscopy procedure itself.
Report 45398 alone when the banding occurs during the colonoscopy; do not combine it with other banding codes for separate procedures.

Anesthesia CPT code for colonoscopy

The anesthesia CPT code for a colonoscopy depends on the type of procedure:

For anesthesia provided during a screening colonoscopy, use CPT code 00812. This code specifically covers anesthesia for lower intestinal screening colonoscopy procedures, often administered by CRNAs or anesthesiologists to minimize patient discomfort.
If the colonoscopy starts as screening but becomes diagnostic, then anesthesia is reported with code 00811 along with the appropriate modifiers.

To summarize:

Screening colonoscopy anesthesia: CPT 00812.
Diagnostic colonoscopy anesthesia: CPT 00811 with modifiers.

This distinction is important for accurate billing depending on the clinical context of the colonoscopy.