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45378

Diagnostic Colonoscopy

Code Description

CPT code 45378 is used to report a diagnostic colonoscopy performed to examine the lining of the colon and rectum using a flexible endoscope. During the procedure, the physician advances a colonoscope through the rectum to evaluate the large intestine for abnormalities, disease, or sources of gastrointestinal symptoms.

Diagnostic colonoscopy is commonly performed to investigate gastrointestinal bleeding, abdominal pain, changes in bowel habits, and abnormal imaging findings.

When to Use 45378

Common examples include:

  • rectal bleeding

  • unexplained abdominal pain

  • chronic diarrhea

  • change in bowel habits

  • abnormal imaging findings

  • colorectal cancer evaluation

Documentation Requirements

Documentation should include:

  • indication for the procedure

  • extent of examination

  • bowel preparation quality

  • procedural findings

  • patient tolerance

  • diagnostic conclusions

Common Billing Mistakes

Common billing mistakes include:

  • reporting a diagnostic colonoscopy when a therapeutic service was performed

  • failure to document cecal intubation

  • insufficient procedural findings

  • incorrect screening versus diagnostic coding

  • incomplete endoscopy reports

Related CPT Codes
45380

Colonoscopy With Biopsy

45385

Colonoscopy With Polypectomy

45384

Colonoscopy With Lesion Removal

FAQ
What is the difference between CPT 45378 and 45380?

CPT 45378 is a diagnostic colonoscopy without tissue sampling, while CPT 45380 includes obtaining a biopsy during the procedure.

Is CPT 45378 used for screening colonoscopies?

No. Screening colonoscopies are typically reported using different coding guidelines and may require modifier usage depending on payer requirements.

How far must the colonoscope be advanced for CPT 45378?

The examination generally must reach the cecum or surgical anastomosis to qualify as a complete colonoscopy.

When should a therapeutic colonoscopy code be reported instead?

If a biopsy, polypectomy, lesion removal, or other therapeutic intervention is performed, the appropriate therapeutic colonoscopy code should be selected instead of CPT 45378.

Procedure Type

Colonoscopy

Body Area

Technique

Colon

Diagnostic Endoscopy