Current Procedural Terminology (CPT) codes describe medical services and procedures for administrative purposes, including billing and communication with insurance providers. Among the most frequently referenced codes are those related to colonoscopies, a procedure central to colorectal cancer screening and prevention. Understanding the precise meaning of codes like 45380, the technique involved, and its administrative context offers clarity to patients and helps explain medical billing.
Defining Code 45380
CPT code 45380 represents a procedure described as: Colonoscopy, flexible, with biopsy, single or multiple. This code specifically covers the visual examination of the entire large intestine, extending from the rectum to the cecum, often including the terminal ileum. The scope must be advanced past the splenic flexure, which is the sharp bend in the colon located near the spleen, ensuring a complete examination of the entire colon.
The core action defining CPT 45380 is the performance of a tissue biopsy, which means taking a small sample of tissue for laboratory analysis. This biopsy is typically performed using cold biopsy forceps, a tool that pinches off a piece of tissue. While a biopsy is a form of tissue removal, it is generally considered a diagnostic step to understand the nature of a lesion, distinguishing it from a complete therapeutic removal. The code that specifically covers the complete removal of a lesion using the snare technique is CPT code 45385.
Understanding the Snare Technique
The snare technique, which is the definitive method for polyp removal billed under CPT 45385, uses a specialized device deployed through the working channel of the colonoscope. This device consists of a thin, flexible wire loop, or snare, attached to a long catheter. The physician maneuvers the loop to encircle the base of the abnormal growth, or polyp.
Once the wire loop is securely positioned around the polyp’s stalk or base, the loop is slowly tightened, effectively trapping the tissue. An electrosurgical current is then delivered through the wire, which achieves two simultaneous actions. The electrical energy acts as a cutting tool to cleanly sever the polyp from the colon wall. The heat generated by the current also provides a coagulation effect, which cauterizes the blood vessels at the resection site to prevent bleeding. This combined cutting and coagulation process, often referred to as hot snare polypectomy, is the standard technique for removing polyps larger than a few millimeters.
Essential Documentation and Billing Context
Proper use of CPT code 45385 requires detailed documentation from the physician that clearly supports the complete removal of a lesion by snare. The medical record must specify the size and exact anatomical location of the removed lesion, such as the ascending colon or the sigmoid colon. Furthermore, the note must explicitly confirm that the snare technique was the method of removal.
A core billing principle involves the concept of “bundling,” where a higher-level therapeutic code includes the lower-level diagnostic code. If a colonoscopy begins as a diagnostic procedure (CPT 45378) and a polyp is found and removed by snare (CPT 45385), only the therapeutic code (45385) is reported. The diagnostic portion is considered an inherent part of the more complex removal procedure and is not billed separately. The use of administrative modifiers becomes necessary only when multiple distinct lesions are treated with different techniques. For example, if a physician removes one polyp with a snare and takes a separate biopsy from a different area, a modifier must be applied to the codes to indicate that two distinct procedures were performed on separate lesions.
How 45385 Differs from Other Colonoscopy Codes
CPT code 45385, the snare polypectomy code, is distinct from other codes based on the intervention performed during the colonoscopy. The base procedure is a purely visual, or diagnostic, colonoscopy, which is coded as 45378 when no tissue is sampled or removed. Code 45380 is used for obtaining a tissue sample via biopsy forceps, typically for smaller lesions or for sampling a larger lesion.
Other distinct codes exist for different removal methods. Code 45384 represents the removal of a lesion using hot biopsy forceps, a technique involving smaller forceps that also apply electrosurgical current, often for smaller polyps. Another code, 45388, is used when a lesion is destroyed or ablated, such as with argon plasma coagulation, rather than physically removed. The choice between these codes hinges entirely on the tool used and the intent of the intervention—sampling, complete physical removal, or destruction.