Gastroenterology billing involves managing medical codes, claims, and payments for procedures related to the digestive system. It ensures that gastroenterologists receive accurate reimbursement for services such as colonoscopies, endoscopies, and other digestive health treatments.
Because these procedures require precise documentation, many practices rely on specialized medical billing services to handle coding and claim submission efficiently.Suppose, if a patient visits a gastroenterologist with stomach pain and a colonoscopy reveals a small polyp that is removed using the snare technique, the correct code to bill is CPT 45385.
This guide explains the CPT 45385 procedure code in detail, covering billing guidelines, documentation tips, and common errors so you can submit clean, accurate gastroenterology claims every time.
45385 CPT Code Description
CPT Code 45385 is used when a routine colonoscopy turns into a therapeutic procedure. If the physician finds a polyp or abnormal growth during the exam and removes it immediately, the procedure changes from a screening to a treatment session.
The primary goal of this procedure is to identify and remove polyps before they can become cancerous. The doctor performs this using a snare technique, a looped wire that tightens around the base of the polyp and removes it.
There are two types of snare methods, the cold snare, used for very small polyps under 5 mm, and the hot snare, used for larger polyps. CPT code 45385 covers both techniques.
When to Use CPT Code 45385
CPT code 45385 is often applied in colonoscopy procedures when polyps are removed. Here are three common situations to illustrate its use:
1. Hot Snare Removal of an Adenomatous Polyp
Adenomatous polyps, or adenomas, are the most frequently encountered colon polyps. While most are harmless, they can develop into colorectal cancer if left untreated. Suppose if a 55 year old man undergoes a routine screening colonoscopy due to a family history of colorectal cancer. A 6 mm adenomatous polyp is removed with a hot snare, and CPT code 45385 is used for billing.
2. Cold Snare Removal of Multiple Serrated Polyps
Serrated polyps appear in roughly 30% of colonoscopies. Though only a minority progress to cancer, their faster growth makes early removal important. Let’s take an example if a 45 year old woman visits her doctor for unexplained diarrhea. During a colonoscopy, the physician removes two small serrated polyps (3 mm and 4 mm) using a cold snare, reporting the procedure with CPT code 45385.
3. Removal of Recurrent Polyps in Follow-Up Colonoscopy
Polyps can reappear after initial removal, with 25-30% of patients having new polyps in follow-up exams. Timing depends on previous polyp size and type. Suppose a 61 year old woman returns three years after large polyps were removed. A new 6 mm adenoma is excised with a hot snare during her follow-up colonoscopy, and CPT code 45385 is billed.
4. Removal of Sessile Polyps During a Diagnostic Colonoscopy
Sessile polyps are flat or slightly raised growths in the colon. They are more difficult to detect and remove than pedunculated polyps. However, they can still become cancerous if left untreated. Suppose a 58 year old man complains of mild abdominal discomfort. During a diagnostic colonoscopy, the gastroenterologist identifies a 7 mm sessile polyp in the ascending colon and removes it using a hot snare. The procedure is billed with CPT code 45385.
Supported Modifiers for Billing 45385 CPT Code
Modifiers help clarify the circumstances under which CPT Code 45385 (colonoscopy with polypectomy) was performed. Using the correct modifier ensures accurate colonoscopy billing, prevents claim denials, and supports proper reimbursement. Here are the most commonly used modifiers for this code:
1. Modifier PT
Indicates that the colonoscopy began as a screening but became therapeutic or diagnostic after a polyp was found and removed.
2. Modifier 22
Used when the colonoscopy is unusually difficult or complex, requiring significantly more time or effort than usual.
3. Modifier 53
Applies when the procedure is started but must be stopped for medical or safety reasons before completion.
4. Modifier 59
Reports that another procedure was performed during the same session that is separate and distinct from the primary service.
5. Modifier 52
Used when only part of the procedure is performed, but not the entire service as described by CPT Code 45385.
Correctly applying these modifiers is essential for compliance and accurate reimbursement in colonoscopy billing.
How to Bill and Get Reimbursed for CPT Code 45385
Incorrect coding of CPT Code 45385 for polyp removal is a common cause of claim denials, resulting in lost time and revenue. To ensure accuracy and maximize reimbursement, follow these expert tips for billing CPT 45385 correctly.
Verify Payer Specific Rules for CPT Code 45385
While the Affordable Care Act generally covers colorectal cancer screening, payer policies can vary. Some insurers may apply co-payments or coinsurance if a screening becomes a therapeutic procedure.
Always confirm that CPT Code 45385 is covered with no patient cost-sharing under the plan. Performing an eligibility check before billing speeds up reimbursement and enhances patient satisfaction.
Use CPT Code 45385 Precisely
CPT 45385 applies when a colonoscopy involves the removal of polyps, tumors, or other lesions using a snare technique, with or without electrocautery.
Do not confuse this code with other polypectomy codes such as 45380 (cold biopsy) or 45384 (hot biopsy). Double-check all code descriptions before claim submission to ensure accuracy.
Document Thoroughly for CPT Code 45385
Incomplete documentation is a leading reason for denied claims. Each operative note should clearly state whether the colonoscopy was performed for screening, diagnosis, or follow-up. Include details such as:
- Number, size, and location of all polyps removed
- Removal technique used (e.g., snare, electrocautery)
- ICD-10 diagnosis codes showing medical necessity
- Any specimens sent for pathology and their findings
Complete, accurate documentation not only supports proper reimbursement but also protects the provider during audits.
Sequencing Modifiers with CPT Code 45385
If you need to use more than one modifier, the order is important. Always put the modifier that affects payment first, and then add the modifier that only gives extra information.
Conclusion
The CPT Code 45385 stands out in the field of gastroenterology to ensure proper and accurate billing for colonoscopy procedures involving polyp removal. From hot to cold snare techniques, coding and documentation have a direct bearing on reimbursement and compliance.
To reduce claim denials by up to 20% and speed up reimbursement, follow payer-specific rules, use the appropriate modifiers (such as PT, 22, or 59), and maintain detailed operative notes.
Collaborating with gastroenterology billing service providers streamlines the process and reduces errors. This helps maximize reimbursement and allows physicians to focus more on patient care.
