CPT 45380

Colonoscopy with Biopsy

Colonoscopy, flexible, with biopsy, single or multiple, by forceps technique.

30-50 minutes
4.43 work RVU
6 requirements

Documentation Requirements

  1. 1All diagnostic colonoscopy elements (indication, consent, prep, extent)
  2. 2Biopsy site(s) with anatomic location
  3. 3Number of biopsies obtained
  4. 4Technique used (cold forceps, hot forceps)
  5. 5Specimen sent to pathology documented
  6. 6Post-biopsy hemostasis confirmed

Billing Tips

  • •Do not bill 45378 separately — 45380 includes the diagnostic component
  • •Bill per session, not per biopsy site
  • •Multiple biopsy sites in same session = single 45380
  • •If polypectomy also performed, use appropriate polypectomy code instead
  • •Document each biopsy location for medical necessity

Frequently Asked Questions

Can I bill 45378 and 45380 together?

No, 45380 includes the diagnostic colonoscopy component. You should not bill 45378 separately when biopsies are taken during the same session. Scribeable ensures correct code selection.

How does Scribeable handle colonoscopy with biopsy notes?

Scribeable captures your procedure dictation and generates notes documenting all biopsy sites, technique, specimen handling, and pathology orders — ensuring compliant 45380 documentation.

Automate Colonoscopy w/ Biopsy Documentation

Scribeable captures all required elements for CPT 45380 from your patient conversation. Generate compliant notes in seconds.

Common Diagnoses

K51.90K50.90D12.6K63.5K92.1

Related Specialties

gastroenterologysurgery

Related Procedures

CPT 453783.69 work RVU

Colonoscopy

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

CPT 432393.25 work RVU

EGD with Biopsy

Esophagogastroduodenoscopy (EGD), flexible, transoral, with biopsy, single or multiple.

CPT 930000.29 work RVU

EKG

Electrocardiogram, routine ECG with at least 12 leads, with interpretation and report.

CPT 992042.60 work RVU

New Patient Level 4

New patient office visit with moderate level of medical decision making.

CPT 45380: Colonoscopy with Biopsy

Colonoscopy, flexible, with biopsy, single or multiple, by forceps technique.

Documentation Requirements

  1. All diagnostic colonoscopy elements (indication, consent, prep, extent)
  2. Biopsy site(s) with anatomic location
  3. Number of biopsies obtained
  4. Technique used (cold forceps, hot forceps)
  5. Specimen sent to pathology documented
  6. Post-biopsy hemostasis confirmed

Billing Tips

  • Do not bill 45378 separately — 45380 includes the diagnostic component
  • Bill per session, not per biopsy site
  • Multiple biopsy sites in same session = single 45380
  • If polypectomy also performed, use appropriate polypectomy code instead
  • Document each biopsy location for medical necessity

Frequently Asked Questions

Can I bill 45378 and 45380 together?

No, 45380 includes the diagnostic colonoscopy component. You should not bill 45378 separately when biopsies are taken during the same session. Scribeable ensures correct code selection.

How does Scribeable handle colonoscopy with biopsy notes?

Scribeable captures your procedure dictation and generates notes documenting all biopsy sites, technique, specimen handling, and pathology orders — ensuring compliant 45380 documentation.

Related Procedures

Specialties

Compare

Clinical Content

Resources

Getting Started