CPT Digestive Questions for the CCS Exam — Practice Free

For a professional service, an incomplete colonoscopy that reaches the splenic flexure but not the cecum is reported using the colonoscopy code (e.g., 45378) with modifier -53 (Discontinued Procedure). If the scope does not reach the splenic flexure, it is coded as a sigmoidoscopy (45330). Rationale: CPT defines a complete colonoscopy as reaching the cecum or terminal ileum. AHIMA Exam Tip: Distinguish between modifier -53 (physician's choice for patient safety/prep) and modifier -52 (reduced services) which is used in the facility setting for the same scenario.

Report only 45380. Rationale: CPT 45380 covers single or multiple biopsies by any method (brushing or forceps). When multiple methods are used to obtain a sample from the same site or even different sites, the code is only reported once per encounter. Clinical Pearl: Brushing is considered a form of biopsy in the CPT Digestive hierarchy. Do not unbundle 45380 for multiple samples.

Report 45384 only. Rationale: Both hot biopsy forceps and bipolar cautery (ablation) fall under the same CPT code 45384 (Removal by hot biopsy forceps or bipolar cautery). Since the code description includes single or multiple, it is only reported once regardless of how many polyps were removed using these specific techniques. CCS Exam Tip: Always check if the code description says single or multiple to avoid over-coding.

Report 45385 (Snare) and 45381 (Submucosal injection). Rationale: 45381 is used for tattooing or for lifting a lesion with saline. Unlike control of bleeding, tattooing (45381) is not bundled into the polypectomy codes (45385/45384) and can be reported separately. Use modifier -XS or -59 if required by the payer to show it is a distinct service, though many NCCI edits allow this combination as they are distinct therapeutic actions.

Report 45378 (Colonoscopy) and 43235-51 (EGD). Rationale: These are from two different families of codes (Esophagus vs. Lower GI). They are not subject to the multiple endoscopy base-code reduction rule, but are subject to standard multiple procedure discounts. Sequence the highest-valued procedure first (usually the colonoscopy). AHIMA focuses on correct modifier application (-51 for multiple procedures in different systems).