CPT 45380: Colonoscopy with Biopsy
Colonoscopy with tissue biopsy collection. Includes visualization of entire colon, biopsy collection, and post-procedure monitoring.
Why CPT 45380 Claims Get Denied
Claims billed under CPT 45380 are frequently denied or downcoded for the following reasons. Understanding these patterns helps your practice reduce denial rates and recover revenue faster.
Medical necessity documentation missing
Frequency limitations exceeded
Over-coding with multiple biopsy codes
Bundling with surveillance codes
Inadequate documentation of indication
Billing Tips for CPT 45380
Document clear indication (screening, follow-up of known polyp, etc.). Include number and location of biopsies. Separate pathology findings. Include note on whether surveillance interval can be determined. Document tolerability and any complications.
Documentation Requirements
To support a clean claim for CPT 45380, your clinical documentation should include:
Indication for colonoscopy
Pre-procedure evaluation
Sedation details
Visualization findings
Biopsy locations and sites
Number of biopsies collected
Pathology results or pending status
Polyp management if any
Surveillance interval assessment
Common Modifiers for CPT 45380
Reduce CPT 45380 Denials by 60%
RediClaim's pre-submission scrubber catches documentation gaps and coding errors before you submit, while the appeal generator handles denials that slip through.