Colonoscopy (July 2004)

July 2004 page 15-end Coding Clarification:Colonoscopy The CPT Assistant has received a number of follow- up questions related to the article “Colonoscopy Coding Made Simple” that appeared in the January 2004 CPT Assistant. Many of the questions refer back to a Question and Answer response in CPT Assistant January 1996 that stated: “The appropriate code for a colonoscopy with removal of a polyp by a cold biopsy is 45380 or 45385 depending on the actual technique employed.... CPT code 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article clarifies a colonoscopy coding topic discussed in CPT Assistant, focusing on how report language and removal technique affect CPT code selection. It is intended for coders, physicians, and other billing professionals who review colonoscopy documentation and need to understand the general areas covered by updated interpretation guidance.

Why This Topic Matters

Colonoscopy documentation often uses imprecise terms, and this clarification explains why terminology in the operative note must be interpreted carefully. It helps readers understand the broader coding issues discussed in the article and why older guidance was revisited.

Article Sections

  1. Coding Clarification: Colonoscopy

    The article discusses follow-up clarification from CPT Assistant on colonoscopy reporting, including terminology commonly seen in procedure notes and the broader issue of technique-based coding interpretation.

  2. Current coding interpretation and reminders

    This section emphasizes that coding guidance can change over time and that readers should consult the most recent CPT Assistant material for current interpretation.

What You Will Learn

  • How the article frames colonoscopy coding clarification within CPT Assistant guidance
  • Why procedure terminology in colonoscopy documentation can require careful interpretation
  • What general kinds of technique-based distinctions are discussed in colonoscopy reporting
  • Why readers are directed to current CPT Assistant issues for updated guidance

Who Should Read This

  • Medical coders
  • Physicians
  • Billing staff
  • Compliance staff
  • Revenue cycle professionals

Codes Discussed


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