Significant changes in Current Procedural Ter- minology (CPT)* coding are being implement- ed in 2015, although not all of these changes
were accepted by the Centers for Medicare & Medicaid Services (CMS). This article provides reporting and payment information about the codes that
are relevant to general surgery and its closely related specialties.
Lower GI endoscopy
A number of revisions were made to the lower gastrointestinal (GI) endoscopy codes in the Colon and
Rectum subsection of CPT. Definitions were revised
or added at the beginning of the subsection and new
guidelines were created to further clarify reporting
of these procedures:
•Colonoscopy is the 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.
•Colonoscopy through stoma is the examination of
the colon, from the colostomy stoma to the cecum,
and may include examination of the terminal ileum
or small intestine proximal to an anastomosis.
•When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and
prepared for a total colonoscopy, if the physician is
unable to advance the colonoscope to the cecum or
colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or
44388 (colonoscopy through stoma) with modifier
53 (discontinued procedure) and provide appropriate documentation.
•If a therapeutic colonoscopy (44389–44407, 45379,
45380, 45381, 45382, 45384, 45388, 45398) is performed
and does not reach the cecum or colon-small intestine
anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 (reduced services) and
provide appropriate documentation.
• Report flexible sigmoidoscopy (45330–45347) for endoscopic examination during which the endoscope is not
advanced beyond the splenic flexure.
• Report flexible sigmoidoscopy (45330–45347) for endoscopic examination of a patient who has undergone
resection of the colon proximal to the sigmoid (eg,
subtotal colectomy) and has an ileo-sigmoid or ileo-rectal anastomosis. Report pouch endoscopy codes
(44385, 44386) for endoscopic examination of a patient
who has undergone resection of colon with ileo-anal
anastomosis (eg, J-pouch).
•Report colonoscopy (45378–45398) for endoscopic
examination of a patient who has undergone segmental resection of the colon (eg, hemicolectomy, sigmoid
colectomy, low anterior resection).
•For colonoscopy through stoma, see 44388–44408.
Report proctosigmoidoscopy (45300–45327), flexible
sigmoidoscopy (45330–45347), or anoscopy (46600,
46604, 46606, 46608, 46610, 46611, 46612, 46614,
46615), as appropriate for endoscopic examination of
the defunctionalized rectum or distal colon in a patient
who has undergone colectomy, in addition to colonoscopy through stoma (44388–44408) or ileoscopy
through stoma (44380, 44381, 44382, 44384) if appropriate.
As part of the review of the lower GI endoscopy
codes, several stent placement and ablation CPT codes
were deleted and new CPT codes were created that
added the words “pre- and post-dilation and guide
wire passage, when performed” to the descriptor.
*All specific references to CPT (Current Procedural Terminology) codes
and descriptions are © 2014 American Medical Association. All rights
reserved. CPT and CodeManager are registered trademarks of the
American Medical Association.