Skip to main content
45380

Colonoscopy, flexible; with biopsy, single or multiple

Surgery Gastrointestinal System - Endoscopy 8.28 Total RVUs
Quick Reference
For colonoscopy with biopsy of colonic mucosa for diagnostic purposes

💬 Plain Language Explanation

What this means

This is a colonoscopy with biopsy - a procedure where a doctor examines your colon and removes small tissue samples for testing.

Why you might see this

This code is used when your colonoscopy included taking tissue samples (biopsies) for testing. This is done when the doctor finds something that needs to be examined under a microscope.

Common context

Used when colonoscopy includes taking tissue samples for testing, often when polyps or abnormalities are found.

What to ask your provider

"'What did the biopsies show? Were there any abnormal findings?'"

Relative Value Units (RVUs)

Calculator →
Work RVU
2.80
Physician effort
PE RVU
5.20
Practice expense
MP RVU
0.28
Malpractice
Total RVU
8.28
Combined value
Dollar reimbursement rates vary by locality and payer. RVUs shown for relative comparison only.
Calculate Payment

Clinical Information

When to Use

For colonoscopy with biopsy of colonic mucosa for diagnostic purposes

Time Requirement
20-35 minutes typical procedure time

Common Scenarios

Colonoscopy with biopsy for inflammatory bowel disease
Colonoscopy with biopsy of suspicious lesions
Colonoscopy with biopsy for surveillance of dysplasia
Colonoscopy with multiple biopsies for staging
Colonoscopy with biopsy for abnormal imaging findings

Documentation Requirements

  • Indication for colonoscopy and biopsy
  • Location of each biopsy site
  • Number of biopsies taken
  • Endoscopic appearance of biopsied lesions
  • Reason for biopsy at each site

Coding Guidelines

Common Modifiers

59 Distinct procedural service if performed with other procedures
33 Preventive service when performed for screening
52 Reduced services if procedure not completed
53 Discontinued procedure due to patient condition

Bundling Rules

  • Includes colonoscopy
  • Includes single or multiple biopsies
  • Polypectomy requires separate code
  • Biopsy forceps use bundled
  • Upper endoscopy coded separately if performed same session

Exclusions

  • 45378 (diagnostic colonoscopy without biopsy)
  • 45385 (colonoscopy with polypectomy)
  • 45381 (colonoscopy with directed injection)
  • 45382 (colonoscopy with control of bleeding)

Coding Notes

No global period - diagnostic procedure
Multiple biopsies from same site count as single biopsy
Document each biopsy location separately
Biopsy specimens should be labeled by location

Clinical scenarios

Colonoscopy with biopsy for inflammatory bowel disease
Colonoscopy with biopsy for inflammatory bowel disease
When to use:For colonoscopy with biopsy of colonic mucosa for diagnostic purposes
  • Indication for colonoscopy and biopsy
  • Location of each biopsy site
  • Number of biopsies taken
Colonoscopy with biopsy of suspicious lesions
Colonoscopy with biopsy of suspicious lesions
When to use:For colonoscopy with biopsy of colonic mucosa for diagnostic purposes
  • Indication for colonoscopy and biopsy
  • Location of each biopsy site
  • Number of biopsies taken
Colonoscopy with biopsy for surveillance of dysplasia
Colonoscopy with biopsy for surveillance of dysplasia
When to use:For colonoscopy with biopsy of colonic mucosa for diagnostic purposes
  • Indication for colonoscopy and biopsy
  • Location of each biopsy site
  • Number of biopsies taken

Who are you?

Code Details

Code 45380
Category Surgery
Subcategory Gastrointestinal System - Endoscopy
Total RVUs 8.28

Medicare Pricing

PFS
2025 National Rate
$414.68
Facility
$192.79
Non-Facility
$414.68
RVU Breakdown
Work RVU:3.56PE RVU:8.79MP RVU:0.47Total RVU:12.82CF:$32.3465Global Days:000
OPPS Details
APC:5312Status:TCopayment:—
ⓘ Physician Fee Schedule: Medicare pays physicians based on Relative Value Units (RVUs) multiplied by a conversion factor.

Were You Charged for This?

Check Your Bill

Compare your charges against Medicare rates

NCCI Bundling Check

Can 45380 be billed with another code?

Full NCCI Checker

Automate Coding

Let OrbDoc AI automatically suggest codes from your clinical notes.

Patient? Check your bill.

Use our free analyzer to understand charges and spot errors.

Analyze My Bill

Ask OrbDoc AI

Get instant answers about 45380 - pricing, bundling rules, or billing questions.

Ask a Question

Frequently Asked Questions

What is CPT code 45380?

CPT 45380 is the billing code for "Colonoscopy, flexible; with biopsy, single or multiple". For colonoscopy with biopsy of colonic mucosa for diagnostic purposes

How much does Medicare pay for CPT 45380?

Medicare pays approximately $414.68 for CPT 45380 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.

What are the RVUs for CPT 45380?

CPT 45380 has a total RVU of 8.28, broken down as: Work RVU 2.80, Practice Expense RVU 5.20, and Malpractice RVU 0.28. RVUs (Relative Value Units) determine Medicare reimbursement rates.

What documentation is required for CPT 45380?

Key documentation requirements for CPT 45380 include: Indication for colonoscopy and biopsy; Location of each biopsy site; Number of biopsies taken; Endoscopic appearance of biopsied lesions. Missing or incomplete documentation is a leading cause of claim denials for this code.

Can CPT 45380 be billed with other codes?

Bundling considerations for CPT 45380: Includes colonoscopy. Includes single or multiple biopsies Use an NCCI bundling checker to verify specific code combinations before billing.

What modifiers are commonly used with CPT 45380?

Common modifiers for CPT 45380 include: 59 (Distinct procedural service if performed with other procedures), 33 (Preventive service when performed for screening), 52 (Reduced services if procedure not completed). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.

What is the time requirement for CPT 45380?

The typical time requirement for CPT 45380 is 20-35 minutes typical procedure time. Time-based codes require documentation of the actual time spent providing the service.

Related resources