CPT code 45380, 45381 – Colonoscopy flexible

by | Jan 2, 2022 | CPT modifiers

CPT Code Code Descriptor

45380 Colonoscopy, flexible; with biopsy, single or multiple

45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance

Colonoscopy – CPT Codes 45378-45398, G0105, G0121

The American Society for Gastrointestinal Endoscopy (ASGE) works to ensure that adequate methods are in place for gastroenterology practices to report and obtain fair and reasonable reimbursement for procedures, tests and visits. To assist practices in understanding and implementing GI-specific coding, ASGE has developed coding sheets. The purpose of the coding sheet is to provide a high-level overview to support practices in there coding and reimbursement for 2018.

What is a Colonoscopy?

It is an examination of the entire colon, from the rectum to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.


The CPT© codes in this series identify services performed during Colonoscopy.

CPT Codes for Colonoscopy (45378-45398)

How will the Endoscopic Adjustment Rule be applied to multiple endoscopy codes within the same family (same Endoscopic Base Code) billed on the same day by the Same Group Physician and/or Other Health Care Professional?

A: Below is an example of how the Endoscopic Adjustment Rule will be applied:

In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), the Endoscopic Adjustment Rule will pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378) or Adjusted Allowable for (45380).

The calculation of the Adjusted Allowable for the lesser valued endoscopy code(s) in the same family is as follows:

a. Determine the Adjusted RVU: Lesser valued endoscopy code(s) RVU minus the Endoscopic Base Code RVU

b. Determine the Percentage to Allow: Adjusted RVU (Step 1a) divided by the lesser valued RVU = ratio (percentage to allow for the lesser valued endoscopy code).

c. Determine the Adjusted Allowable for the lesser code(s): Lesser valued code fee schedule x ratio (Step 1b) = endoscopic adjusted allowable for the lesser valued code.

Based on the following RVUs for these codes if the procedures were performed in a facility: 45378 (6.48), 45380 (7.73) and 45385 (9.17), Oxford would reimburse the full value of 45385 ($374.56), plus the Adjusted Allowable for 45380 ($45.76). The Endoscopic Base Code (45378) is not reimbursed.

Note: RVU values and dollar amounts in this example may not accurately reflect the current NPFS and are intended for illustrative purposes only.

Code Description Facility RVU Adjusted RVU Percentage to Allow Adjusted Allowable
45380 Colonoscopy, flexible; with biopsy,
single or multiple 7.73 7.73 – 6.48 = 1.25 1.25/7.73 = 16% 285.98 x 16% = $45.76

How will the Endoscopic Adjustment Rule be applied to multiple endoscopy codes within the same family and another procedure that is not related?

A: Below is an example of how the Endoscopic Adjustment Rule and multiple procedure reduction will be applied when the physician bills for codes 45380 and 45381 (same endoscopic family) and 45562 (unrelated procedure).

a. First determine the Total Adjusted RVU for each endoscopic family. Each “family” of endoscopic codes is considered as a single procedure (RVUs combined) for ranking.

b. Rank the Family Adjusted RVUs against other reducible procedures RVUs from highest to lowest.

c. Apply the Multiple Procedure Reduction (Example: Standard reduction of 100-50-50).

Based on the following RVUs for these codes if the procedures were performed in a facility: 45378 (6.48), 45380 (7.73), 45381 (7.34) and 45562 (33.19), first calculate the Total Adjusted RVUs based on the Endoscopic Adjustment Rule by subtracting the difference between the Endoscopic Base Code and the lower valued endoscopy code (.86) and then adding that calculation to the higher valued endoscopy code (7.73), which equals (8.56). Compare the Family Adjusted RVUs (8.56) to the RVUs of the unrelated procedure (33.19) to determine Multiple Procedure Ranking.


Note: RVU values and dollar amounts in this example may not accurately reflect the current NPFS and are intended for illustrative purposes only.

lines or with a number greater than 1 in the units column on the claim form or inappropriately billed with modifier ‘-78’ (i.e., after the global period has expired);

  1. “Access Field 34 of the MFSDB to determine the Medicare fee schedule payment amount for each surgery;
  2. “Access Field 21 for each procedure of the MFSDB to determine if the payment rules for multiple surgeries apply to any of the multiple surgeries billed on the same day;
  3. “If Field 21 for any of the multiple procedures contains an indicator of ‘0,’ the multiple surgery rules do not apply to that procedure. Base payment on the lower of the billed amount or the fee schedule amount (Field 34 or 35) for each code unless other payment adjustment rules apply;
  4. “For dates of service prior to January 1, 1995, if Field 21 contains an indicator of ‘1,’ the standard rules for pricing multiple surgeries apply (see items 6-8 below);
  5. “Rank the surgeries subject to the standard multiple surgery rules (indicator ‘1’) in descending order by the Medicare fee schedule amount;
  6. “Base payment for each ranked procedure on the lower of the billed amount, or:
    • 100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure;
    • 50 percent of the fee schedule amount for the second highest valued procedure; and
    • 25 percent of the fee schedule amount for the third through the fifth highest valued procedures;
  7. “If more than five procedures are billed, pay for the first five according to the rules listed in 5, 6, and 7 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, ‘by report.’ Payment determined on a “by report” basis for these codes should never be lower than 25 percent of the full payment amount;
  8. “For dates of service on or after January 1, 1995, new standard rules for pricing multiple surgeries apply. If Field 21 contains an indicator of ‘2,’ these new standard rules apply (see items 10-12 below);
  9. “Rank the surgeries subject to the multiple surgery rules (indicator ‘2’) in descending order by the Medicare fee schedule amount;
  10. “Base payment for each ranked procedure (indicator ‘2’) on the lower of the billed amount:
    • 100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure; and
    • 50 percent of the fee schedule amount for the second through the fifth highest valued procedures; or
  11. “If more than five procedures with an indicator of ‘2’ are billed, pay for the first five according to the rules listed in 9, 10, and 11 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, ‘by report.’ Payment determined on a ‘by report’ basis for these codes should never be lower than 50 percent of the full payment amount. Pay by the unit for services that are already reduced (e.g., 17003). Pay for 17340 only once per session, regardless of how many lesions were destroyed;
  12. “If Field 21 contains an indicator of ‘3,’ and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. Access Field 31A of the MFSDB to determine the base endoscopy.

“Example: In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).

“Carriers assume the following fee schedule amounts for these codes:
• 45378 – $255.40
• 45380 – $285.98
• 45385 – $374.56
“Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.

“NOTE: If an endoscopic procedure with an indicator of ‘3’ is billed with the ‘-51’ modifier with other procedures that are not endoscopies (procedures with an indicator of ‘1’ in Field 21), the standard multiple surgery rules apply. See §§40.6.C.6-8 for required actions.

COLONOSCOPY CATEGORIES (See Below):

  1. Diagnostic / Therapeutic Colonoscopy – Patient has gastrointestinal symptoms, colon polyps, or gastrointestinal disease requiring evaluation or treatment by colonoscopy (CPT Code: 45380 – See # 1 below).
  2. Surveillance / High Risk Colonoscopy Screening – Patient is asymptomatic (no present gastrointestinal symptoms) and has a personal history of Crohns’ Disease, Ulcerative Colitis, or a personal or direct relative with colon polyps, and/or colon cancer. Patients in this category are required to undergo colonoscopy surveillance at shortened intervals (usually every 2 – 5 years) and depending on your insurance carrier, this category may be reimbursed as if you were having a diagnostic colonoscopy (CPT Code: 45378 – See #2 below).
  3. Preventive / Average Risk Colonoscopy Screening (Included as part of the Affordable Care Act) – Patient is asymptomatic (no present gastrointestinal symptoms), is 50 years old or older and has no personal history of gastrointestinal disease, colon polyps, and/or cancer. Patients in this category have not undergone a colonoscopy within the last 10 years (CPT Code: 45378 – See #3 below).

https://content.findacode.com/files/documents/medicare/ncci/2019/CHAP6-CPTcodes40000-49999_final103118.pdf
The NCCI PTP edit with column one CPT code 45385 (Flexible colonoscopy with removal of tumor(s), polyp(s), or lesion(s) by snare technique) and column two CPT code 45380 (Flexible colonoscopy with single or multiple biopsies) is often bypassed by utilizing modifier 59. Use of modifier 59 with the column two CPT code 45380 of this NCCI PTP edit is only appropriate if the two procedures are performed on separate lesions or at separate patient encounters.

If multiple endoscopies are billed, special rules for multiple endoscopic procedures apply.

Medicare contractors shall perform the following actions when multiple CPT/HCPCS codes with a payment policy indicator of ‘3’ (Special Rules for Multiple Endoscopies), with the same date of service, are present:

  1. Identify if the billed codes share the same Endoscopic Base Code (using the Physician Fee Schedule Payment Policy Indicator File).
  2. If the same base is shared, pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy.

EXAMPLE: In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).

Assume the following fee schedule amounts for these codes:

45378 – $255.40
45380 – $285.98
45385 – $374.56
Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.

Colorectal Cancer Screening (COL)

One prevention and screening measure for the Centers for Medicare & Medicaid Services (CMS) Star ratings system and the Healthcare Effectiveness Data and Information Set (HEDIS®) is Colorectal Cancer Screening (COL). This measure evaluates the percentage of members 50 to 75 years of age who had appropriate screening for colorectal cancer through the performance of a fecal occult blood test (FOBT), flexible sigmoidoscopy or colonoscopy. Below are the Current Procedural Terminology (CPT®), Current Procedural Technology Category II (CPT II), Healthcare Common Procedure Coding System (HCPCS), and ICD-9-CM Procedure codes that indicate these services have been performed.

45380 Colonoscopy, flexible; with biopsy, single or multiple

The RUC reviewed the survey results of 152 gastroenterologists, general surgeons, and colon and rectal surgeons and recommends the following physician time components: pre-service time of 27 minutes, intra-service time of 28 minutes and post-service time of 15 minutes. The RUC agreed with the specialties that pre-service package 1B Facility straightforward patient and procedure with sedation was appropriate with two additional minutes for left lateral decubitus positioning of the patient, and to position the endoscopy equipment/monitor, and anesthesia lines/equipment prior to induction of moderate sedation.

The RUC reviewed the respondents’ estimated physician work values and agreed that the current work RVU of 4.43, the survey median, is too high considering the drop in total time from the current time to the surveyed time. The RUC agreed that the appropriate methodology for valuing this service is to use the RUC established increment. The RUC previously established a work RVU of 0.30 in the upper GI endoscopic family of services for the additional work of performing a biopsy over the base diagnostic procedure. Therefore, the RUC added the approved 0.30 work RVUs to CPT code 45378 (RUC recommended work RVU = 3.36) to arrive at a work RVU of 3.66 for 45380, which is lower than the current value.

To justify a work RVU of 3.66, the RUC compared the surveyed code to MPC code 52214 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands (work RVU= 3.50) and noted that while the reference code has 2 additional minutes of intra-service time, 45380 is a more intense procedure and is correctly valued higher than this MPC code. In addition, the RUC reviewed CPT codes 57461 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix (work RVU= 3.43, intra time= 28 minutes) and 31629 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) (work RVU= 4.09, intra time= 40 minutes) and agreed that with comparable physician work and similar total times, these reference codes offer appropriate brackets for the recommended value. The RUC recommends a work RVU of 3.66 for CPT code 45380.

Discussion and Recommendation

45380 Colonoscopy, flexible; with biopsy, single or multiple

We recommend an RVW of 3.81 for 45380. This value is less than the current and 25th percentile RVW and is equal to the recommendation for the colonoscopy base code 45378 plus an established increment of 0.30 (43201-43200; 43239-43235; 43261-43260; 44382-44380; 44385-44386; 45330-45331) approved by the RUC for endoscopic biopsies.

Pre-time Package 1b is appropriate for 45380, with an additional 2 minutes for left lateral decubitus positioning of the patient and to position the endoscopy equipment/monitor, and anesthesia lines/equipment relative to the patient prior to induction of moderate sedation.

Comparison to Key Ref 31625

Key Reference code 31625, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites, was surveyed and presented to the RUC in 2003 prior to the discussion of pre-time packages. The survey data for 45380 from 2003 is comparable to the current survey data for 31625, but the intensity and complexity data indicate that 45380 is more intense and complex than 31625 with 45380 ranking higher in 10/11 measures

Colonoscopy Procedures

Coding guidelines for Colonoscopy procedures:

• Use CPT code 45378 for a Diagnostic Colonoscopy. There will be a symptom prompting the test and this is not a screening procedure for Medicare. However, you may use this code for screening procedures billed to payors other than Medicare.

• CPT code G0105 is to be used for a Colonoscopy done for Cancer Screening on an Individual at High Risk. These procedures are covered every 24 months for Medicare patients.

• High risk is defined as a personal history of any of the following:

  1. Colorectal cancer;
  2. Personal history of adenomatous polyps;
  3. Some Inflammatory Bowel disorders, such as Crohns Disease or Ulcerative Colitis;
  4. The patient has a close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyposis;
  5. The patient has a family history of familiar adenomatous polyposis; or
  6. The patient has a family history of nonpolyposis colorectal cancer.

• The G0121 procedure code is to be used for a Screening Colonoscopy done on an Individual not meeting the criteria for High Risk. Colonoscopies for Medicare patients of average risk (not at high risk) are covered by Medicare once every 10 years.

• It is not necessary to use the G-codes for Screening Colonoscopy procedures on claims going to payors other than Medicare. Use the 45378 code, unless a biopsy is taken (45380) or a polyp is removed.

• The Diagnosis codes to use for Screening Colonoscopies appear in the V-code section of the ICD-9-CM book. Medicare has issued LCDs in many states on Colonoscopies, which include covered circumstances and covered diagnosis codes – check Medicare policies or with your Carrier for this information and review it carefully. The basic screening code is V76.51.

• If, during the course of a Screening Colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, it should be billed with a Biopsy or Polypectomy code pertaining to what was performed, instead of as a Screening procedure.

• For either a Colonoscopy or EGD procedure, if a lesion is biopsied, and then subsequently the SAME lesion is removed during the same operative session, code the removal of the lesion only.

• For either a Colonoscopy or EGD procedure, if the one lesion is biopsied, and a separate lesion is removed during the same operative session, code both the biopsy of the lesion and the removal of the separate lesion. Append a –59 Modifier to the biopsy procedure.

• For Colonoscopy procedures performed involving Biopsies and/or the Removal of a Polyp using Cold Biopsy Forceps, use CPT code 45380 for Biopsy(s), for the removal of portions of a polyp by cold biopsy forceps, and for the removal of an entire polyp by cold biopsy forceps. This is referred to as “cold”, since the electric current is running to the instrument and no cauterization of bleeding takes place during the removal of the tissue.

• If the physician intends to perform a Diagnostic Colonoscopy (CPT code 45378), but he/she cannot complete the procedure (due to medical complications), the 45378 code should be billed, appending the –74 Modifier for Terminated Procedure. Some payors prefer the use of the -52 Reduced Services Modifier, instead of the -74 for a Terminated procedure.

• To qualify for billing a Colonoscopy code, the scope must move beyond the Splenic Flexure of the Colon. If the scope is not able to move that far, and is only used to examine as far as the Sigmoid Colon and a portion of the Descending Colon, it should be coded as 45378 with a –52 Modifier.

• If the patient has a particularly long GI tract, and the physician runs out of scope before viewing the entire colon, (for example, the scope goes past the Splenic Flexure, but does not extend all the way to the Cecum) – these procedures should have a –52 Modifier appended for billing purposes.

• Failed Colonoscopies are also referred to as “incomplete”. This occurs when the scope is not able to be advanced past the splenic flexure. Causes of this problem include incomplete preps, unusual patient anatomy, the patient has an obstructing lesion, or the provider performing the procedure is inexperienced. These procedures are coded as 45378-74, with the – 74 Modifier indicating a Discontinued Procedure. Some payors might prefer the use of the -52 Modifier, instead of the -74 Modifier.

• Biopsies – Code 45380. Use this code for the removal of a portion of a polyp or an entire polyp by cold biopsy forceps, in which disposable forceps is used. This is referred to as “cold”, since no electric current is running to the instrument and no cauterization of bleeding takes place during the removal of the tissue. Tissue samples (biopsies) are taken.