45385

Colonoscopy, flexible, diagnostic and therapeutic, including collection of specimen(s) by brushing or washing, when performed, and including removal of tumor(s), polyp(s), or other lesion(s) by snare technique

CPT code 45385 describes a flexible colonoscopy procedure that combines both diagnostic and therapeutic elements. During this procedure, a flexible endoscope is inserted through the anus and advanced through the entire large intestine (colon) to visualize the mucosal lining. The diagnostic component involves thorough examination for abnormalities, and may include the collection of tissue specimens via brushing or washing. The therapeutic component specifically involves the removal of tumor(s), polyp(s), or other lesion(s) utilizing a snare technique, typically with electrocautery, to resect the identified lesion from the colonic wall. This code encompasses the entire procedure, including visualization, biopsy (if performed on a separate lesion or for diagnostic purposes not related to snare removal), and the definitive snare excision.

Clinical Indications

  • Removal of colorectal polyps or suspicious lesions identified during a diagnostic colonoscopy or other imaging studies.
  • Screening for colorectal cancer in average-risk individuals where polyps are found and removed.
  • Surveillance for colorectal cancer or recurrence in high-risk individuals or those with a history of polyps or cancer, where new lesions are found and removed.
  • Investigation and treatment of lower gastrointestinal bleeding (e.g., hematochezia, positive fecal occult blood test) when a bleeding polyp or lesion is identified and resected.
  • Evaluation and treatment of chronic diarrhea, unexplained abdominal pain, or change in bowel habits where a treatable lesion is found and removed.
  • Follow-up for abnormal findings from a prior colonoscopy, flexible sigmoidoscopy, or other imaging techniques.

Procedure Steps

  1. Patient undergoes bowel preparation to ensure a clear colon.
  2. Administration of moderate sedation, deep sedation, or general anesthesia.
  3. Digital rectal examination is performed.
  4. The flexible colonoscope is inserted into the rectum and carefully advanced through the sigmoid, descending, transverse, and ascending colon, ideally reaching the cecum or terminal ileum.
  5. A thorough visual inspection of the entire colonic mucosa is performed during insertion and withdrawal.
  6. Identification of polyps, tumors, or other lesions requiring removal.
  7. The snare technique is employed to encircle the base of the lesion. Electrocautery is typically applied through the snare to cut and coagulate the tissue, facilitating removal and minimizing bleeding.
  8. Retrieved specimens (polyps/lesions) are collected for pathological examination.
  9. Any bleeding resulting from the polypectomy site is controlled (e.g., with cautery, clips, or injection).
  10. If indicated, additional biopsies may be taken from other areas of concern (e.g., for inflammatory conditions).
  11. The colonoscope is slowly withdrawn, and the remaining colon is inspected.
  12. Post-procedure recovery and observation.

Coding Guidelines

  • Code 45385 is used when one or more polyps or lesions are removed by snare technique during a flexible colonoscopy. It includes the diagnostic component and any associated biopsies (e.g., for surveillance or evaluation of the remaining mucosa).
  • If multiple lesions are removed by snare technique during the same operative session, 45385 is reported only once, regardless of the number of lesions removed by snare.
  • Do not report 45385 in conjunction with a diagnostic colonoscopy code (e.g., 45378) if a snare polypectomy is performed, as 45385 encompasses the diagnostic service.
  • If different removal techniques are used on separate lesions (e.g., one lesion removed by snare, another by biopsy forceps), report 45385 for the snare removal and 45380 (biopsy) for the biopsy. Modifier 59 may be required to indicate distinct procedural services.
  • For a screening colonoscopy that becomes therapeutic (e.g., a polyp is found and removed by snare), report 45385. The primary diagnosis code should reflect the screening indication (e.g., Z12.11) with additional codes for the findings (e.g., K63.5).
  • Documentation must clearly describe the findings, location, size, morphology, and the method of removal for each lesion.
  • If a colonoscopy is incomplete (i.e., not advanced to the splenic flexure or beyond), it should be reported with modifier 52 (Reduced Services) or the appropriate unlisted code, depending on payer guidelines and the extent of the procedure performed and documented.

Associated ICD-10 Codes