Current Procedural Terminology (CPT®) 2015 brought several new definitions and many code changes for gastroenterology. New prefatory language for endoscopy of the small and large intestines better defines the procedures and provides instruction for reporting instances when less than the defined procedure is performed.

As was the case with codes for laryngoscopy and esophagoscopy in 2014, CPT now better defines each procedure and replaces “with or without” in the code descriptors with “including…when performed.” Note that when the term when performed is included in a code descriptor, this excludes separate reporting of the referenced service(s) but does not require performance to report the code.

For example, consider code 45388, colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed). While pre- and post-dilation and guide wire passage are not separately reported when performed in conjunction with flexible colonoscopy...

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