Current Procedural Terminology (CPT) codes provide a uniform system for describing medical procedures and services for administrative purposes. CPT code 45385 identifies a specific type of therapeutic colonoscopy, involving both examination and surgical intervention within the large intestine. This code signifies that a growth was found and removed during a complete colonoscopy using a specialized technique.
The Clinical Description of CPT 45385
CPT 45385 describes a flexible colonoscopy that includes the removal of one or more tumors, polyps, or other lesions. During the procedure, a physician uses a long, flexible tube called a colonoscope to examine the entire inner lining of the large intestine, from the rectum to the cecum. The scope contains a camera and light source, allowing the specialist to visualize the intestinal wall for abnormalities.
The primary purpose of this procedure is to detect and remove growths before they become cancerous. Colorectal cancer often develops from abnormal growths called adenomatous polyps, which are identified and excised during the colonoscopy. The procedure shifts from a purely diagnostic examination to a therapeutic intervention the moment a lesion is acted upon, distinguishing CPT 45385 from a simple diagnostic colonoscopy.
The colonoscopy is considered complete when the scope successfully reaches the cecum, which is the beginning of the large intestine. This full examination ensures that all segments of the colon are inspected for potential disease. Although multiple lesions may be removed, CPT 45385 is reported only once per operative session, regardless of the number of polyps removed by that method.
The Technical Nuances
The distinguishing factor of CPT 45385 is the use of the snare technique for lesion removal. The snare is a thin, wire loop passed through a channel in the colonoscope and looped around the base of the polyp or tumor. This method allows the physician to encircle the growth and tighten the wire to excise the tissue.
The snare technique differs from a simple biopsy, which uses forceps to pinch off tissue for testing, or a hot biopsy using electrocautery. The snare is preferred for removing larger polyps, typically those greater than 5 millimeters in diameter. Physicians may use a cold snare, which excises the polyp without electrical current, or a hot snare, which uses electrocautery to cut and simultaneously cauterize the base of the polyp to prevent bleeding.
The full description of CPT 45385 also implies that the colonoscope was advanced proximal to the splenic flexure. The splenic flexure is a sharp bend in the colon where the transverse colon turns downward. “Proximal to” means the scope was advanced beyond this bend, into the transverse or ascending colon.
This anatomical detail is important because it confirms that the physician performed a comprehensive examination of the entire colon, not just the lower portion. A colonoscopy that only reaches the splenic flexure or an area short of the cecum is considered an incomplete procedure and would be billed with a different code and a modifier.
Administrative and Financial Implications
The application of CPT 45385 has direct consequences for patient billing and insurance coverage. The code represents a therapeutic service, meaning the physician performed an action to treat a condition, which is a distinction from a purely screening procedure. Screening colonoscopies are performed on asymptomatic patients to look for disease and are often covered fully by insurance plans under preventive care mandates.
When a polyp is found and removed using the snare technique (CPT 45385) during a screening procedure, the service is reclassified as a therapeutic intervention. This change can alter the patient’s financial responsibility, as the procedure transitions from screening to a diagnostic or treatment service. The patient may then be responsible for a co-pay, co-insurance, or a portion of the deductible, depending on the insurance plan’s policy.
To reflect that the procedure began with a preventive intent, a special modifier, such as modifier 33 or PT, is often appended to CPT 45385 when submitted to the insurer. Modifier 33 is generally used for commercial insurance, while modifier PT is for Medicare, indicating that the screening turned therapeutic. This modifier is an administrative tool intended to help ensure the claim is processed correctly under preventive service rules.
The final bill for a procedure coded as 45385 is typically broken down into two components: the professional fee and the facility fee. The professional fee covers the physician’s service, while the facility fee covers the costs associated with the hospital or outpatient center, including equipment, supplies, and staff. Both fees are impacted by the shift from screening to therapeutic procedure, making it important for patients to understand the coding to anticipate their out-of-pocket costs.