CPT Code 45384 Complete Billing & Coding Guide for Colonoscopy with Hot Biopsy Forceps

CPT 45384 represents a flexible colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) using the hot biopsy forceps technique.

The treatment colonoscopy is performed when small polyps or lesions are found and removed using electrocautery forceps. This technique enables the simultaneous removal and cauterization of tissue, which minimizes the risk of bleeding. 

CPT 45384 is commonly performed in gastroenterology, but the code is often used incorrectly because it is incorrectly paired with the biopsy or snare procedure, is not understood for the purpose of bundling, or is not applied correctly during a screening conversion modifier. 

Correct identification of removal technique, lesion characteristics, and the intent for the procedure is important for accurate coding. 

CPT 45384 – Description

Official Definition:

“Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.”

This procedure includes:

• Flexible colonoscope insertion and complete examination (typically to the cecum or proximal colon)
• Removal of lesion(s) using hot biopsy forceps
• Electrocautery-assisted tissue excision and coagulation
• Diagnostic colonoscopy component included.

Key clarifications:

• Procedures performed with biopsy forceps that are heated to remove tissue = CPT 45384 
• Cold forceps biopsy without cautery = CPT 45380
• Snare polypectomy = CPT 45385
• Only one code is reported per technique unless distinct procedures are performed

Clinical Indications (When CPT 45384 Is Used)

CPT 45384 is used when small or superficial lesions are identified and removed using hot biopsy forceps.

Common indications include:

• Small polyps or lesions of the rectum or colon (usually not cancerous or insignificant in size). 
• Colonoscopy with incidental removal of polyps. 
• Evaluation of suspected mucosal abnormalities
• Patients with previous polyps should have the procedure performed for surveillance. 
• Removal of flat or superficial lesions unsuitable for the snare technique
• Positive stool-based screening tests require intervention

CPT 45384 is performed when a screening colonoscopy is converted to a therapeutic procedure, in most cases, for the removal of lesions. 

Reimbursement Insights Under CPT Code 45384

Billing for CPT 45384 depends on the payer type, setting, and procedural complexity. 

• Generally, lower professional fees are negotiated when the facility provides a variety of technical services. 
• Non-facility settings include higher practice expense RVUs
• Commercial payer reimbursement is contract-based and generally higher
• Under the Physician Fee Schedule, Medicare uses geographic adjustments. 
• Global period: 000 (no postoperative days included)
• Screening-to-therapeutic conversion significantly impacts patient liability and reimbursement structure

Applicable Modifiers Under CPT Code 45384

Correct modifier usage is key to billing compliance for CPT 45384. 

• -PT (Medicare): If the colonoscopy is being used as a screening tool and it turns into a therapeutic procedure because of removal of the lesion. 
• -33 (Preventive Services): Applied when the removal of a lesion was for its preventive purposes, even if the lesion was removed at the same time. 
• -59 / X{EPSU}: Used when different techniques are performed on separate lesions (e.g., hot biopsy + snare)
• -22 (Increased Procedural Services): For complex cases which involve additional work and documentation for the physician 
• -52 (Reduced Services): Used when procedure is partially completed based on payer policy
• -53 (Discontinued Procedure): Used when procedure is terminated due to medical or technical issues

All modifier usage must be supported with detailed operative documentation.

Documentation Requirements For CPT Code 45384

Documentation is essential for reimbursement and compliance with CPT 45384. 

The following are important components of documentation: 

• Diagnostic or screening or surveillance
• The colon's length examined
• Number, size and location of lesions
• Description of the shape of the lesions.
• Removal technique (hot biopsy forceps with cautery).
• The details of hemostasis and cauterization. 
• The collection and sending of specimens and pathology.
• Quality of bowel preparation
• Interruption due to complications or procedural limitations 
• Physician report with authentic signatures 

Example Clinical Scenarios For CPT Code 45384

Scenario 1: Screening Colonoscopy with Hot Biopsy Removal

A man is having a colonoscopy screening. A small sigmoid polyp is found and excised by hot biopsy forceps with cautery. 

→ Coding Outcome: CPT 45384

→ Rationale: Screening was changed to therapeutic procedure as a result of the removal of lesions.

Scenario 2: Surveillance Colonoscopy with Multiple Small Lesions

A patient who had polps in the past has a colonoscopy for surveillance. A small area of skin with two small lesions is taken out with hot biopsy forceps. 

→ Coding Outcome: CPT 45384 (single unit)

→ Rationale: Multiple lesions are removed with the same technique, they are bundled. 

Scenario 3: Screening Conversion with Medicare Modifier

A screening colonoscopy is performed. A diminutive polyp is removed using hot biopsy forceps.

→ Coding Outcome: CPT 45384 with modifier -PT

→ Rationale: Screening converted to therapeutic intervention.

Scenario 4: Mixed Techniques in Same Session

A hot biopsy forceps removal is performed on one lesion and snare polypectomy is performed on another lesion.

→ Coding Outcome:

• CPT 45385 (primary higher-value procedure)
• CPT 45384 with modifier -59/X (if supported and distinct)

→ Rationale: Distinct techniques performed on separate lesions.

BillingFreedom Known For Gastroenterology Medical Billing Built on High-Performance Revenue Cycle Standards

At BillingFreedom, our gastroenterology medical billing and coding framework is built on a performance-driven revenue cycle model designed specifically for high-volume endoscopy practices, including CPT 45384 and related colonoscopy procedures.

Our structured coding validation and denial-prevention process has been designed to achieve a high first pass claim acceptance rate (typically 97% - 99%) and a strong adherence to CMS, MAC and commercial payer guidelines. 

We have a multi-layered compliance approach that includes clinical coding accuracy, modifier validation and a payer-specific rule enforcement to help cut down on financial leakage in colonoscopy-driven workflows. 

Core Performance Metrics Observed Across GI Billing Operations

• 97%–99% Claim acceptance rate
• Below 1% denial rate
• Clean claim submission rate: 95%+
• 18–28 days Average A/R cycle time
• Revenue recovery improvement: up to 15%–25%
• Coding accuracy rate after internal QA review: 98%+

Colonoscopy Billing Control System Includes

The entire revenue cycle for colonoscopy and polypectomy is tightly managed, including in the following aspects: 

• Proper coding of screening, diagnostic colonoscopy, and therapeutic (polypectomy) cases (45378, 45380, 45384, and 45385)
• Modifier governance including -PT, -33, -59, X{EPSU}, -52, -53, and -22 with documentation-backed validation
• Preventing improper bundling of diagnostic and therapeutic services by NCCI edit resolution.
• Correct tracking of screening to therapeutic conversion for pathways to reimbursement
• Medical necessity and LCD alignment of claims for lesion removal and colorectal screening.
• Pre-submission claim review for accuracy and completeness of the code
• Review for pathology with regard to consistency at the specimen level.
• Implementing denial analytics feedback loop for continuous improvement. 

Operational Impact on Gastroenterology Practices

Typically, gastroenterology groups partnering with BillingFreedom see the following through this structured model:

• Reduced claim rework, resulting in faster reimbursement cycles.
• Improved net collections due to coding leakage correction.
• Reduce the exposure to denial in colonoscopy and polypectomy patients
• Stability of payer compliance in Medicare and commercial contracts.
• Simplified billing operations for billing teams.
• Documentation alignment checks to improve audit readiness. 

All billable workflows are tied to CMS guidelines, AMA CPT structure and payer-specific LCD policies. The system provides the most accurate reimbursement with minimal audit or compliance risk exposure. 

If you want to know more about our outstanding Gastroenterology medical billing services, feel free to get in touch with us by sending an email at info@billingfreedom.com or call us at +1 (855) 415-3472. 

We want you to be financially at rest!