Excellent Coding Tips for CPT code 45378

Description about CPT code 45378

In this procedure, the physician performs flexible colonoscopy. During this procedure physician may obtain brushings or washings. The colonoscope is inserted through the anus, into the colon and then into cecum. The lumen of colon and rectum are visualized. Brushings or washing may be obtained during this exam. The colonoscope is removed once the procedure is done. This procedure is a Separate Procedure. CPT code 45378 should be coded only when it is performed alone. The exact description of CPT code 45378 as given in codebook is given below:
Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
Excellent Coding Tips for CPT code 45378

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When to use CPT code 45378   

As I have told you CPT code 45378 is a separate procedure, hence it will a component of most of the complex procedures and is not coded separately. Only scenario is when it is performed alone we can bill CPT code 45378. In addition, if separate procedure is performed with complex or any unrelated procedure and is not include in the complex procedure, we can bill both with modifier 59 with the separate procedure. Hence, we can bill CPT code 45378 along with complex procedure if not included with the complex procedure code. Moderate conscious sedation is included in CPT code 45378 and hence should not be reported separately with this CPT code. However, anesthesia services (00100-01999) may be billed separately when performed by a physician (or other qualified provider) other than the physician performing the procedure. Medicare and some other payers may require HCPCS Level II codes G0105 or G0121 be reported for this service.

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Do and Don’t with CPT code 45378

Do not code any procedure code for colon exam or terminal ileum exam along with CPT code 45378-45378. These procedures are included with these procedures.
Control of bleeding during same operative session result of an endoscopic procedure, is included in CPT code 45378-45398
Do code CT exam performed (74261-74263) for colonography. It is not included in these procedures.
Do use modifier 53 (physician) or 73, 74 (facility) for any incomplete colonoscopy.

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