CPT® Code 45331

A flexible sigmoidoscopy is a diagnostic procedure that allows for the examination of the lower part of the colon, specifically the sigmoid colon, using a flexible tube known as a sigmoidoscope. This procedure can be performed with or without the collection of specimens, which may include brushing or washing techniques as indicated in CPT® code 45330. In the case of CPT® code 45331, the procedure specifically involves the collection of single or multiple biopsies. During the procedure, the sigmoidoscope is carefully inserted into the anus and advanced through the rectum into the sigmoid colon. Air insufflation is utilized to expand the colon and separate the mucosal folds, allowing for a thorough inspection of the mucosal surfaces. Any abnormalities such as ulcerations, varices, bleeding sites, lesions, or strictures are noted during this examination. After the initial inspection, the endoscope is withdrawn, and a second inspection of the mucosal surfaces is conducted to ensure that no abnormalities are missed. If necessary, a brush can be introduced through the endoscope to collect cytology samples, or sterile water may be used to wash the mucosal lining, with the fluid then aspirated to obtain cell samples. In the context of CPT® code 45331, any suspicious areas identified for biopsy are targeted, and biopsy forceps are introduced through the endoscope's biopsy channel. The forceps are then opened to capture tissue samples, which are subsequently removed through the endoscope. This procedure allows for the collection of one or more tissue samples, which are then sent for laboratory analysis to aid in diagnosis and treatment planning.