We all know that medical billing is a complex process that includes using various coding systems, such as CPT, ICD-10, and HCPCS, to code the provided services accurately. Coding itself requires expertise and special training.
In this blog, we will decode everything about CPT code 45384, a gastroenterology code. This code reports the removal of polyps, lesions, or abnormal growth (tumors) inside the intestine.
Continue reading to find out the detailed description of CPT code 45384, its applicable modifiers, and the billing guidelines that prevent claim denials.
CPT Code 45384 – Description
A colonoscopy is an inspection of the inside of your large intestine (colon), which diagnoses gastrointestinal conditions like colon cancer and inflammatory bowel disease and treats these conditions.
CPT code 45384 reports a colonoscopy, flexible, with the removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps.
In simple terms, a medical professional will insert a flexible colonoscope (a tubelike device with a light source and camera) to check the colon and rectum for abnormalities. If the physician finds any abnormal growths or lesions inside the colon, he removes them in the same session with the help of heated biopsy forceps.
Scenarios Where CPT Code 45384 is Applicable
Let’s look at some clinical scenarios that necessitate the reporting of CPT code 45384.
Discovering and Removing Small Colon Polyps
Suppose a 70-year-old patient visits the clinic with a complaint that he is expelling bright red blood with stool. To find out the cause of rectal bleeding, the gastroenterologist performs a flexible colonoscopy. He discovers small colon polyps (less than 5 mm) in the patient’s large intestine that have the potential to become cancerous if they grow in size.
Hence, the physician removes the polyps in the same session using hot biopsy forceps. He will later apply CPT code 45384 for reimbursement.
Discovering and Removing Large Colon Polyps
Let’s imagine a man in his early 40s who visits the clinic and complains of constant abdominal pain and abnormal bowel changes, such as diarrhea, constipation, or incontinence. The physician asks him to go for a colonoscopy.
While performing the procedure, the physician discovers that there are large polyps (more than 10 mm in diameter) on the lining of the colon and rectum. So he decides to remove them on the spot using a hot biopsy forceps technique. Later, he reports CPT code 45384 for the reimbursement of these services.
Discovering and Removing Colon Lesions
To understand this scenario, think about a 60-year-old man experiencing abdominal pain, persistent constipation, and sudden weight loss in a few weeks. Furthermore, he has been vomiting for the past 24 hours. He visits a gastroenterologist who performs a colonoscopy.
During the procedure, the gastroenterologist discovers some lesions on the rectum lining. He removes those lesions using a hot biopsy forceps technique to relieve the symptoms. In this scenario, he can apply CPT code 45384 for the reimbursement of the services he performed.
Follow-up and Removal of New Polyps
Suppose a patient comes back for a follow-up of colon polyps after 5 years. The reason for this follow-up visit is that she is experiencing polyps-related symptoms again, like abdominal pain and sudden bowel changes.
Upon a follow-up colonoscopy, the gastroenterologist discovers more polyps around the colon lining, but at different places than before. He performs the same procedure and removes new polyps with hot biopsy forceps. Therefore, he can claim his reimbursement under CPT code 45384.
Applicable Modifiers for CPT Code 45384
When needed, you may append the following modifiers to code 45384 for coding specificity.
Modifier PT
Modifier PT is applicable when a screening colonoscopy changes into a diagnostic test or a therapeutic procedure. For instance, when a physician performs a colonoscopy purely for screening, finds a small polyp, and removes it using hot forceps, this screening has now been transformed into a diagnostic/therapeutic service. Therefore, modifier PT will be appended to CPT code 45384.
Modifier 53
Modifier 53 indicates that a process was initiated but stopped because of exceptional circumstances or a potential risk to the patient’s health. For example, a physician begins a colonoscopy by providing monitored anesthesia care but discontinues the process due to the patient’s worsening condition or uncontrollable bleeding.
Modifier 59
Modifier 59 (Distinct Procedural Service) indicates that the procedures are independent, stand-alone, and not part of a single, packaged service. In the case of CPT code 45384, the physician may use modifier 59 if removing the lesions calls for a different method.
CPT Code 45384 – Billing & Reimbursement Guidelines
Don’t let denials keep you away from the dollars you deserve. Follow the guidelines mentioned below to submit clean and compliant claims for your flexible colonoscopy covered by CPT code 45384.
Ensure Appropriate Use of Code 45384
You must ensure the selection of the most suitable CPT code for your colonoscopy services.
Before choosing a CPT code, identify the process, whether it is a screening exam, a diagnostic procedure, or a procedure with additional interventions, like a biopsy or polypectomy, to ensure coding accuracy.
Colonoscopy has various closely related codes that may create confusion for physicians, such as:
45378: Diagnostic colonoscopy, flexible, including specimen collection.
45380: Flexible colonoscopy with biopsy, single or multiple.
45382: Flexible colonoscopy with control of bleeding, any method.
45385: Flexible colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
As you can see, CPT code 45384 is closely related to CPT code 45385. Code 45385 denotes a snare approach for lesion removal, whereas CPT code 45384 refers to the excision of abnormal growths utilizing hot biopsy forceps.
Use Appropriate Modifiers When Needed
Appending the appropriate modifier (when required) is as crucial as using the correct CPT code. Modifier PT specifies when a screening colonoscopy is changed to a diagnostic test or a therapeutic procedure. Your claims could be rejected or remain underpaid if the modifiers are missing or incorrect.
Pair with the Appropriate ICD-10 Diagnosis Codes
Another vital factor to consider while billing and coding is the diagnosis code. Your selection of the ICD-10 diagnosis code must support the therapeutic flexible colonoscopy, covered by CPT code 45384, for the procedure to be medically necessary.
For example, if the colonoscopy resulted in the removal of a polyp, you will apply the K63.5 ICD-10 diagnosis code to report a polyp of the colon.
Provide Detailed Documentation
Now that you are clear about the correct CPT code, modifier, and diagnosis code usage, let’s discuss the documentation requirements for CPT code 45384. Your supporting documentation should include:
- Complete and updated patient information, including the patient’s full name, address, insurance plan details, and medical history.
- Correct service date
- Clinical and operative notes
- Referral letters (if applicable)
- Treatment plan
You must also ensure:
- The documents are signed by the physician or a non-physician staff.
- The documents support the medical necessity of the colonoscopy procedure.
- Keeping hard copies of the physician’s notes for the procedure and the results/reports.
Verify Insurance Coverage
In the case of a Medicare beneficiary, you must confirm that the flexible colonoscopy (CPT code 45384) is covered before rendering the service. In certain situations or for routine procedures, Medicare does not reimburse the services, and providers must submit their claims to secondary payers. However, Medicare does cover CPT code 45384.
Medicare will pay for screening colonoscopies once every 24 months for patients who are at high risk of colorectal cancer. For example, if the patient is deemed high risk, Medicare will cover the test once every 120 months or 48 months after a previous flexible sigmoidoscopy. Plus, there is no minimum age requirement.
Conclusion
We tried to include all the information and address all the queries regarding CPT code 45384. To summarize, CPT code 45384 refers to a flexible colonoscopy in which the provider uses a specialized tool known as “hot biopsy forceps” to remove any polyps or lesions.
Additionally, we uncovered all the billing principles you need to know and described some modifiers that are frequently applied to this code. However, if you still find it difficult to code flexible colonoscopies, professional gastroenterology billing services are available for hire. Third-party billing companies, like MediBillMD, can efficiently manage your entire billing process.
