Colonoscopies are one of the most performed procedures in gastroenterology. At the same time, they are also among the most challenging to bill. Why? Because colonoscopies have numerous types. Each is slightly different from the other. This leads to confusion and ultimately claim denials.
CPT code 45330 represents a type of colonoscopy, called sigmoidoscopy. It is an essential procedure used in diagnosing issues in the lower gastrointestinal (GI) tract, and a good source of revenue for healthcare providers. We have created this detailed guide on 45330 to help you understand what this code entails and how you can use it effectively in your billing.
CPT Code 45330 – Description
CPT code 45330 is defined as:
“Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).”
45330 is a gastroenterology procedure. It represents a simple diagnostic sigmoidoscopy. A sigmoidoscopy is a type of colonoscopy. However, unlike colonoscopy, which examines the entire colon, sigmoidoscopy focuses specifically on the lower part of the colon, examining only the rectum and the sigmoid colon.
The procedure is performed with a flexible sigmoidoscope, which is a tubular instrument equipped with a light source and camera. It allows physicians to visualize the internal structures in real-time. The definition explicitly notes that the code encompasses specimen collection via brushing or washing of the examined area.
Additionally, an essential point to note here is that the definition mentions 45330 as a “Separate Procedure”. This phrase indicates that CPT 45330 is considered an inherent part of a more extensive procedure performed at the same anatomical site. Therefore, if a physician performs a more comprehensive service (such as a full colonoscopy) on the same day, the sigmoidoscopy is bundled into that primary service and should not be billed separately.
Scenarios Where CPT Code 45330 is Applicable
CPT code 45330 can be used in a variety of situations. To give you an idea, let’s look at a couple of real-world scenarios in which this code is applicable.
Rectal Bleeding
Suppose a patient comes to a gastroenterologist. He shares with the physician that he has been getting bright red blood in his stool for the past two weeks. He also shares that he feels occasional abdominal cramping and changes in bowel habits. Upon asking, the patient says that he has tried some over-the-counter medications, but nothing has helped.
These symptoms suggest that there might be a source of bleeding in the lower gastrointestinal tract, possibly from hemorrhoids, colitis, or a lesion. However, to accurately diagnose and identify the cause of bleeding, the physician orders a flexible sigmoidoscopy with specimen collection.
In this case, the billing department can use CPT code 45330 to bill the service.
Abdominal Pain
For this scenario, consider a patient with diarrhea and abdominal pain for several weeks who visits a gastroenterologist. The specialist performs a digital rectal exam and notices a swollen rectum. He suspects the patient is suffering from ulcerative colitis.
To adequately examine the lower colon and confirm or rule out the inflammatory disease, the physician performs a flexible sigmoidoscopy and washes the area. Hence, the medical billing department codes the procedure with CPT code 45330 and submits the claim for reimbursement.
CPT Code 45330 – Billing & Reimbursement Guidelines
The following are some vital points to consider while filing claims for CPT code 45330:
Provide Detailed Documentation
Like all other CPT codes, detailed documentation is crucial if you want your claims to be reimbursed. To secure approval and prevent recoupment during audits, your procedure notes must include:
- Indication: Clear statement of symptoms (e.g., “rectal bleeding for 3 weeks”), and a valid ICD-10 diagnosis code.
- Description: Detailed narrative of the exam, noting the extent of visualization (e.g., “scope advanced to 60 cm”).
- Findings: Specific anatomical observations (e.g., “Grade 1 internal hemorrhoids,” “normal mucosa”).
- Interventions: Notation of any brushings or washings collected.
- Safety: Patient positioning, medications administered, and tolerance of the procedure.
Be Mindful of the Billing Restrictions
Code 45330 is bound by many restrictions.
You cannot bill CPT 45330 with full colonoscopy codes (45378-45398) on the same day. The more extensive colonoscopy includes the visualization of the sigmoid and rectum. Additionally, you cannot bill 45330 with 45331-45342, 45346, 45347, 45349, and 45350.
Another point to note is that, as per the guidelines, Medicare requires HCPCS code G0104 for screening flexible sigmoidoscopy on patients with or without signs of a GI disease. CPT 45330 is strictly for diagnostic use and when a flexible sigmoidoscopy is performed on patients with symptoms of a GI disease. Confusing these two will lead to immediate denials for Medicare patients.
Ensure Separate Anesthesia Billing
Sometimes, during the procedure, the physician may have to administer anesthesia to the patient. However, the reimbursement for anesthesia is not included in the 45330. So, you will have to bill it separately using an appropriate code.
Check the Medicare Reimbursement Rate
Reimbursement for CPT code 45330 varies. Every insurance payer has its reimbursement rate, which in turn varies for each locality. However, Medicare’s national average reimbursement amount for CPT code 45330 is $215.10 for non-facility settings and $53.78 for facility settings.
You can check the exact amount for your Medicare Administrative Contractor (MAC) address via the PFS Lookup Tool.
Final Word
With this, our guide comes to an end. Let’s restate the essential points that we discussed above.
CPT code 45330 is a gastroenterology billing code. It is used to bill a flexible sigmoidoscopy. For proper reimbursement, you must provide detailed documentation with your claims. Additionally, you must verify the reimbursement rates and billing restrictions before filing your claims.
However, billing can be frustrating if you are not getting the expected revenue. Let professionals handle your billing and coding operations for better results. Many companies, like MediBillMD, offer quality gastroenterology billing services at affordable rates.
