Saturday, January 24, 2015

new colonospopy code for 2015 - CPT CODE 45399, 45378, 45380 , 45391, 45392

Colonoscopy Coding Updates

New definition
. Colonoscopy is the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. For screening or diagnostic colonoscopy, report 45378 with modifier 53 if unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances and provide appropriate documentation. For therapeutic examinations that do not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

CPT CODE Short Description Summary of Changes
45399 Transabdominal colonoscopy
via colotomy
Code 45355 has been deleted. Report with new code for unlisted colon procedure, 45399
45378 Colonoscopy Colonoscopy is the examination of the entire colon, from the rectum to the cecum or small-intestine anastomosis, and may include the examination of the terminal ileum or small
intestine proximal to an anastomosis.
45379 Foreign body(s) removal “Foreign body(s)” replaces “foreign body.”
45380 Biopsy Not separately reportable with EMR code 45390 for the same lesion.
45381 Submucosal injection Not separately reportable with EMR or control of bleeding described by 45382 and 45390 for the same lesion.
45382 Control of bleeding “Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45381, 45398 for same lesion.
45384 Hot biopsy Bipolar cautery was deleted as an example.
45385 Snare Not separately reportable with endoscopic mucosal
resection described by 45390 for the same lesion.
45386 Dilation New language specifies use of transendoscopic balloon. Dilation of multiple strictures can be reported with the 59 modifier for each additional stricture dilated. Not separately reportable with ablation or stent placement described by 45388, 45389. Use 74360 if fluoroscopic
guidance is performed. 
45388 Ablation Code 45383 has been deleted. New code 45388 includes
balloon dilation, guide wire insertion and ablation. Not
separately reportable with dilation code 45386 for the same
lesion.
45389 Stent placement Code 45387 has been deleted. New code 45389 includes
pre- and post-dilation and guide wire passage. Not
separately reportable with dilation code 45386. Use 74360 if
fluoroscopic guidance is performed. 
45391 Endoscopic ultrasound Now specifies exam limited to the rectum, sigmoid,
descending, transverse, or ascending colon and cecum,
and adjacent structures. Report only once per session.
Not separately reportable with EUS FNA code 45392 or
radiologic ultrasound codes 76872, 76975.
45392 Endoscopic ultrasound with FNA Now specifies exam limited to the rectum, sigmoid,
descending, transverse, or ascending colon and cecum,
and adjacent structures. Report only once per session. Not
separately reportable with EUS code 45391 or radiologic
ultrasound codes 76872, 76942, 76975. 
45390 Endoscopic mucosal resection (EMR) New code 45390 is not separately reportable with biopsy,
submucosal injection, snare or band ligation described by
45380, 45381, 45385, 45398 for the same lesion.
45393 Decompression New code 45393 for decompression for pathologic
distention, such as volvulus or megacolon. Includes
placement of decompression tube when performed. Report only once per session.
45398 Band ligation New code 45398 is not separately reportable with control
of bleeding code 45334 for the same lesion. Do not report
in conjunction with EMR or hemorrhoidectomy described by
45390, 46221. Report control of active bleeding with band
ligation with 45382.

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