Summary & Overview
CPT 45338: Flexible Sigmoidoscopy with Single Lesion Snare Removal
CPT code 45338 represents a flexible sigmoidoscopy with snare removal of a single tumor, polyp, or other lesion. The code captures a common endoscopic procedure that combines diagnostic visualization of the anus, rectum, and sigmoid colon with a therapeutic polypectomy or lesion excision. Nationally, this code matters for outpatient gastroenterology and colorectal care because it affects procedure coding accuracy, outpatient resource use, and payment for minimally invasive lesion removal.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for when the procedure is performed, the typical settings where it occurs (ambulatory surgery centers, hospital outpatient departments, and endoscopy suites), and the service type classification as an endoscopic therapeutic procedure. The publication also outlines common billing considerations and benchmarking topics relevant to payers and providers.
This summary prepares clinicians, billing staff, and policy analysts to understand the code’s clinical purpose, the primary sites of service, and the payer landscape. Data not available in the input are clearly noted where applicable; the report focuses on nationally relevant policy, coding context, and operational implications rather than state-level specifics.
Billing Code Overview
CPT code 45338 describes a diagnostic and therapeutic procedure in which a provider uses a flexible sigmoidoscope to examine the inner anus, rectum, and sigmoid colon and removes a single tumor, polyp, or other lesion using a snare technique. This is an endoscopic excision/removal of a single lesion via flexible sigmoidoscopy.
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Service type: Endoscopic sigmoidoscopy with lesion removal (snare polypectomy)
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Typical site of service: Ambulatory surgery center or hospital outpatient department; may also be performed in endoscopy suites or specialty clinics equipped for flexible sigmoidoscopy.
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient presents to an outpatient endoscopy suite with intermittent rectal bleeding and a positive fecal immunochemical test. The gastroenterologist reviews the history, obtains informed consent, and performs bowel preparation per protocol. Under moderate sedation in an ambulatory surgery center, the provider introduces a flexible sigmoidoscope to examine the anus, rectum, and sigmoid colon. During inspection, a single pedunculated polyp is identified in the sigmoid colon and removed using a snare technique with electrocautery. Specimens are retrieved for pathology, bleeding is controlled, and the patient is monitored in recovery before discharge with post-procedure instructions and pathology follow-up.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Normal, preoperative status | Use when service represents the usual, uncomplicated performance of the procedure |
22 | Increased procedural services | Use when documentation supports substantially greater work or complexity than typical |