Brief Guide to CPT Code 45385

Creating accurate claims and ensuring proper reimbursement for gastroenterology services is not just an administrative task that you can ignore. It is an integral step that ensures the financial health and operational efficiency of your practice.

Providers often struggle to navigate the intricacies of colonoscopy coding, leading to denials and uncompensated care. Therefore, we decided to empower you with knowledge! Yes, with the correct understanding of the nuances between techniques, like snare vs. forceps, you can differentiate between similar codes and ensure precision in billing.

This guide is dedicated to discussing an essential colonoscopy procedure code, CPT code 45385. We will cover everything, from explaining its descriptor to real-world scenarios and billing guidelines.

If you are completely new to this system, check out our complete guide to CPT codes to get familiar with the basics.

So, without further ado, let’s get started.

CPT Code 45385 Description

Do you want to bill it accurately, but don’t know where to start? Then, start by thoroughly reviewing the procedural code descriptor. Oftentimes, there is a slight difference in the technique used, specifically how a lesion is removed, that makes all the difference. Choose the wrong code, and you will commit a serious mistake in medical billing.

Enough with the disclaimer! Let’s understand what the CPT code 45385 descriptor involves. It covers a colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.

A provider performs this procedure by using a colonoscope, a long, flexible tube with a camera, to visualize the large intestine. The “snare technique” is the critical component here. It involves a wire loop (snare) that is slid through the colonoscope, positioned around the base of the growth, and tightened to remove the lesion, often using a small electrical current (cautery).

This procedure is both diagnostic and therapeutic. The doctor examines the colon, and upon detecting a problem, performs an immediate intervention.

Scenarios Where CPT Code 45385 is Applicable

Discussed below are some of the real-world clinical scenarios where CPT code 45385 applies:

Routine Screening with Polyp Detection

Picture a 50-year-old patient with a family history of colon issues who visits for a routine screening colonoscopy. Everything appears normal initially, but during the examination, the physician identifies a polyp in the sigmoid colon. 

Instead of scheduling a separate visit, the physician deploys a snare through the scope and removes the polyp immediately. Here, CPT code 45385 applies because the snare technique was utilized for removal. Note: This often changes the nature of the visit from purely “screening” to “diagnostic,” which can impact patient cost-sharing.

Symptomatic Patient with Rectal Bleeding

Consider a 62-year-old male patient complaining of changes in bowel habits and unexplained rectal bleeding. The physician orders a diagnostic colonoscopy to investigate the source of the symptoms. During the procedure, a lesion is discovered. The provider uses a snare to excise the lesion to send it for pathology. In this situation, CPT code 45385 will be reported for accurate reimbursement.

Follow-up on Previous Findings

Imagine a patient returns for a follow-up procedure because previous polyps were too large to remove in a single session, or the patient was previously on anticoagulants that made removal unsafe at the time. The physician now returns to the site and successfully removes the remaining polyps using the snare technique. CPT code 45385 precisely covers this performed procedure.

Important Note: If the provider removes the polyp using hot biopsy forceps or cold biopsy forceps, do not use this code. The technique dictates the code selection.

Applicable Modifiers for CPT Code 45385

What happens when you encounter a situation where the procedure is interrupted, or multiple distinct procedures are performed? Will the payer pay you for everything? The typical scenario may result in a claim denial if modifiers are not used correctly.

So, how may one avoid falling victim to such denials? Here are the essential modifiers to know:

• Modifier 53 (Discontinued Procedure): Append this if the physician elects to terminate the procedure due to the patient’s well-being (e.g., the bowel preparation was poor, or the patient had a reaction).
• Modifier 59 (Distinct Procedural Service): This is crucial. Use this when a separate procedure is performed on a different site or organ system during the same visit. For example, if a polyp is removed by snare in the ascending colon (45385), and a biopsy is taken from a different lesion in the descending colon using a different technique. This functions similarly to how you might handle distinct services with CPT code 97110 in physical therapy contexts.
• Modifier 76 (Repeat Procedure): Use this to indicate a procedure was repeated by the same physician on the same day.
• Modifier 52 (Reduced Services): Applicable if the procedure was partially reduced or eliminated at the physician’s discretion.

You can learn more about proper modifier usage through resources provided by the Centers for Medicare & Medicaid Services.

CPT Code 45385 – Billing & Reimbursement Guidelines

The following are the essential reimbursement and billing requirements for snare technique colonoscopy:

Demonstrate Medical Necessity

You can never unlock a locked door with the wrong key. The same applies to reimbursement. The payer will never compensate for care services if the procedure is deemed medically unnecessary. Thus, the top requirement is to justify the medical necessity. You must ensure your claim includes the correct diagnosis codes, typically ICD-10 codes related to polyps, benign neoplasms, or abnormal findings, that logically support the procedure.

Ensure Detailed Documentation

Comprehensive and accurate documentation is another integral requirement when billing CPT code 45385. Therefore, your documentation must include the following:

• Indication: Why was the procedure performed? (Screening vs. Diagnostic)
• Technique: Explicitly state that a snare was used. If the notes say “biopsy,” auditors may downcode the claim.
• Findings: Location, size, and number of polyps removed.
• Pathology: Note if the lesion was retrieved for testing.

Avoid Bundling Issues

Do not bill CPT 45385 with other codes that are considered mutually exclusive or bundled by the payer for the same lesion. Understanding your payer’s bundling rules can save you from significant revenue loss.

Conclusion

We have covered a lot of ground in this guide. So, let’s quickly summarize all key takeaways to reiterate the critical details related to CPT code 45385.

• First, we explained that CPT 45385 covers colonoscopy with the removal of tumors, polyps, or lesions using the snare technique.
• Next, we shared clinical scenarios where this applies, such as routine screenings that turn diagnostic or workups for symptomatic patients.
• We emphasized the importance of using modifiers like 59 or 53 to paint a clear picture of the encounter and avoid duplicate claim denials.
• Finally, we discussed the billing guidelines, stressing the need for documentation that explicitly supports the “snare” method.

With all this information, you are now better equipped to differentiate between colonoscopy codes and secure the reimbursement your practice deserves.