CPT code 45378 is to be indicated for a flexible diagnostic colonoscopy performed by a physician. The code is used when the procedure is deemed to be of a diagnostically needed case or screening colonoscopy without any therapeutic intervention, if applicable. In order to correctly report the procedure, there should be outlined certain factors such as the clinical reason for the intervention, the difference between screening and diagnostic procedures, the extent of the procedure, payer requirements, and modification requirements for the process.
CPT Code 45378: Description, Purpose, and What It Includes
45378 CPT Code Description
CPT code 45378 is used for a flexible diagnostic colonoscopy. It is reported when a physician performs a diagnostic procedure that has no reportable therapeutic component.
The 45378 CPT code is used for the examination of the large intestine in the case when an appropriate diagnostic procedure is used to evaluate signs, symptoms, abnormal clinical findings, or other diagnoses. It is also used if a specimen is collected.
Official CPT 45378 Description
The CPT 45378, according to the AMA, is described as follows:
“Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).”
What is Included in the CPT Code 45378?
The code includes the flexible diagnostic colonoscopy with:
- Flexible colonoscope examination
- Diagnostic evaluation of the large intestine
- Scope passage to the cecum, if visualized
- Brushings, washing, and/or specimen collection, if any
- Documentation of bowel preparation
- Documentation of examination findings and the extent of the examination
Moreover, separate procedure codes for diagnostic colonoscopy, biopsy, or polypectomy must be assigned if any of these procedures are performed.
CPT 45378 vs. Other Colonoscopy Codes
| Code | General Purpose |
|---|---|
| 45378 | Diagnostic flexible colonoscopy |
| 45380 | Colonoscopy with biopsy |
| 45384 | Colonoscopy with hot biopsy forceps removal |
| 45385 | Colonoscopy with snare removal |
| 45330 | Flexible sigmoidoscopy |
When Is CPT 45378 Used for Diagnostic Colonoscopy?
Common Clinical Indications
A diagnostic colonoscopy CPT code should be assigned when documentation indicates that the procedure was performed to diagnose any abnormal symptoms or patient history involving the lower gastrointestinal tract. For example, diagnoses like K62.5 – rectal bleeding, D50.9 – iron deficiency anemia, K92.1 – melena, R19.4/R19.5 – change in bowel or fecal habit are indicators for diagnostic colonoscopy.
In addition, the diagnosis may include a family history of cancer of digestive organs (Z80.0), colon polyp (K63.5), ulcerative colitis (K51.x), or Crohn’s disease (K50.x). However, it is noteworthy that the diagnosis should relate to the patient’s problem.
Medical Necessity and Documentation
The diagnosis reported with CPT code 45378 should support medical necessity. It is crucial to relate the indication for the performance of the colonoscopy and the procedure actually performed by the physician. Therefore, it is important to make sure that the diagnosis is adequate to justify the medical necessity of a colonoscopy and properly document the findings during the procedure.
Even if the CPT code is correctly selected, the claim for diagnostic colonoscopy can be rejected due to a coding error or insufficient documentation of medical necessity.
Screening Colonoscopy vs. Diagnostic Colonoscopy
A screening colonoscopy is a procedure performed on an asymptomatic patient as part of a colorectal cancer screening, while a diagnostic colonoscopy is a procedure to evaluate symptoms, abnormalities, or a particular condition.
The difference is considerable because insurance companies make a distinction between the two and reimburse different amounts for screening.
As a result, it becomes critical to differentiate between the two forms of colonoscopy since they have distinct claims and treatment.
Medicare Screening Codes
Medicare screening service codes are:
- G0121 –screening colonoscopy for average risk
- G0105 – screening colonoscopy for high–risk
The codes above are used instead of CPT 45378 when the service is performed as a screening colonoscopy under Medicare.
When Screening Becomes Diagnostic or Therapeutic
A screening colonoscopy may have a diagnostic or therapeutic service if the physician identifies something that requires removal during the procedure. If there is an instance where a polyp was removed, the coder should report a therapeutic procedure instead of simply a screening procedure.
PT Modifier is used for applicable Medicare claims when a screening colonoscopy is converted to a diagnostic or therapeutic procedure.
Complete Versus Incomplete Colonoscopy
A complete colonoscopy usually goes through to the cecum, but the procedure note should indicate how far it was advanced and the quality of the bowel preparation.
Advancing the scope to the splenic flexure is not a complete colonoscopy, and you should report the actual procedure performed when selecting the CPT for colonoscopy.
CPT 45378 Modifiers: PT, 33, and 53
Modifiers are essential when reporting CPT code 45378 because PT, 33, and 53 describe different circumstances.
Modifier PT: Medicare Screening Converted to Diagnostic / Treatment
Modifier PT applies when a patient initially comes for a qualifying screening colonoscopy, but the doctor notices something that requires diagnostic evaluation or urgent treatment. In this case, the initial screening
For example, when a patient comes in for a screening colonoscopy, but the physician finds and removes a polyp, the correct code for therapeutic colonoscopy with PT modifier should be assigned if Medicare guidelines are satisfied.
The documentation of the procedure needs to state that it was initially intended as a screening test, and that there was a finding or intervention that resulted in its conversion to a diagnostic or therapeutic procedure.
Modifier 33: Preventive
Modifier 33 indicates that a service is a qualifying preventive service, and this modifier is usually appropriate for many preventive-service claims, particularly those involving commercial payers.
However, it should be noted that modifier 33 cannot ensure zero patient cost. This is because this depends on the patient’s plan, as well as preventive-service requirements, and continued eligibility of this service as a preventive one.
Modifier 53: Discontinued
Modifier 53 is used to report discontinued procedures in the physician/professional claim if applicable requirements are met.
In the case of an incomplete colonoscopy, the medical record must indicate the reason for termination. If the requirements are met, modifier 53 can be reported with the appropriate procedure code.
PT vs. 33 vs. 53
| Modifier | Primary Context | Purpose |
|---|---|---|
| PT | Medicare | Screening converted to diagnostic/therapeutic |
| 33 | Preventive services | Identifies qualifying preventive service |
| 53 | Physician claim | Discontinued procedure |
These modifiers should not be selected simply because a colonoscopy was performed. The circumstances and payer rules determine whether they apply.
Difference between Modifier 53 and Modifiers 73 and 74
Modifier 53 is used for the physician/professional claim for an applicable discontinued procedure.
Modifiers 73 and 74 are applicable for the outpatient hospital and ASC facility claims.
- 53 – discontinued physician procedure
- 73 – applicable facility procedure discontinued before anesthesia
- 74 – applicable facility procedure discontinued after anesthesia
These modifiers are distinguished by the context in which they are applied and should not be confused with each other.
Difference between Modifier 52 and 53
Modifier 52 means reduced services, and modifier 53 means discontinued procedure
The main difference between them is:
Reduced service is not a discontinued procedure.
Modifier 53 is applicable in the situation when a procedure was begun, but then it was discontinued due to any appropriate cause.
That is why modifier 53 is not the same as modifier 52. The latter implies that the service volume was decreased, but it was provided nevertheless.
Reduced service ≠ discontinued procedure
CPT 45378 Billing Workflow and Key Takeaways
CPT 45378 Billing Workflow
One of the appropriate billing workflows for the CPT code 45378 is listed below:
- Clinical indication
- Screening/diagnostic determination
- Documentation review
- CPT coding
- Modifier review
- ICD-10 linkage
- NCCI/payer review
- Claim submission
Following the steps is essential to make sure that the reported procedure, modifier, and diagnosis are correctly coded.
Gastroenterology Medical Billing Support
The experts in gastroenterology medical billing can assist in selecting the CPT code, checking modifiers, reviewing the documentation, linking diagnoses, preventing claim rejections, and explaining the peculiarities of billing to specific payers.
Conclusion
The CPT code 45378 “Flexible diagnostic colonoscopy” is a separate procedure, which is appropriate for reporting when there is no more specific therapeutic colonoscopy code. In addition, the correct CPT code selection depends on the reason for the procedure, examination documentation, diagnosis, and/or service being screening, diagnostic, therapeutic, or discontinued.
Besides, it is necessary to pay attention to the modifiers. The modifiers PT, 33, 53, 73, 74, and 52 are used for different purposes and should not be confused with each other. Moreover, the code selection is based on the review of the procedure note and the specific requirements of the particular payer. All the above-mentioned considerations help gastroenterology practices avoid coding errors, claim rejections and denials, and ensure appropriate reimbursement.
