CPT 45378

Diagnostic Colonoscopy

Diagnostic colonoscopy, flexible, with or without collection of specimen(s) by brushing or washing, through the stoma if applicable.

30-45 minutes
3.69 work RVU
7 requirements

Documentation Requirements

  1. 1Indication for procedure
  2. 2Informed consent documented
  3. 3Bowel preparation quality assessment
  4. 4Extent of examination (cecum reached or reason if not)
  5. 5Findings described by segment
  6. 6Withdrawal time documented (minimum 6 minutes recommended)
  7. 7Complications or lack thereof

Billing Tips

  • •Base colonoscopy code — do not bill if interventional code (45380-45398) applies
  • •Document cecal landmarks to confirm complete examination
  • •Incomplete colonoscopy may require modifier 53
  • •Screening colonoscopy uses modifier 33 or specific screening codes
  • •Average risk screening: every 10 years starting at age 45

Frequently Asked Questions

What documentation is required for a complete colonoscopy?

Document indication, consent, prep quality, cecal landmarks, segmental findings, withdrawal time, and complications. Scribeable generates structured procedure notes covering all required elements.

How does Scribeable help with colonoscopy documentation?

Scribeable captures procedure dictation in real time and generates comprehensive procedure notes with prep quality, extent of exam, findings by segment, and quality metrics for compliant billing.

Automate Colonoscopy Documentation

Scribeable captures all required elements for CPT 45378 from your patient conversation. Generate compliant notes in seconds.

Common Diagnoses

Z12.11K92.1K57.30K63.5D12.6

Related Specialties

gastroenterologysurgery

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CPT 45378: Diagnostic Colonoscopy

Diagnostic colonoscopy, flexible, with or without collection of specimen(s) by brushing or washing, through the stoma if applicable.

Documentation Requirements

  1. Indication for procedure
  2. Informed consent documented
  3. Bowel preparation quality assessment
  4. Extent of examination (cecum reached or reason if not)
  5. Findings described by segment
  6. Withdrawal time documented (minimum 6 minutes recommended)
  7. Complications or lack thereof

Billing Tips

  • Base colonoscopy code — do not bill if interventional code (45380-45398) applies
  • Document cecal landmarks to confirm complete examination
  • Incomplete colonoscopy may require modifier 53
  • Screening colonoscopy uses modifier 33 or specific screening codes
  • Average risk screening: every 10 years starting at age 45

Frequently Asked Questions

What documentation is required for a complete colonoscopy?

Document indication, consent, prep quality, cecal landmarks, segmental findings, withdrawal time, and complications. Scribeable generates structured procedure notes covering all required elements.

How does Scribeable help with colonoscopy documentation?

Scribeable captures procedure dictation in real time and generates comprehensive procedure notes with prep quality, extent of exam, findings by segment, and quality metrics for compliant billing.

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