CPT 45380: Colonoscopy with Biopsy
Documentation Requirements
- All diagnostic colonoscopy elements (indication, consent, prep, extent)
- Biopsy site(s) with anatomic location
- Number of biopsies obtained
- Technique used (cold forceps, hot forceps)
- Specimen sent to pathology documented
- 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.