CPT® Code 45381

A flexible colonoscopy is a diagnostic and therapeutic procedure that involves the insertion of a flexible tube equipped with a camera, known as a colonoscope, into the rectum and advancing it through the entire colon to the cecum or the terminal ileum. This procedure allows for direct visualization of the mucosal surfaces of the colon, enabling the identification of abnormalities such as polyps, tumors, or inflammatory conditions. During this specific procedure, directed submucosal injections of any substance are administered. Common substances used for these injections include India ink, saline, epinephrine, or corticosteroids. India ink is particularly utilized to delineate a lesion, which is a preparatory step for a separately reportable excision, often referred to as tattooing of the lesion. Saline or epinephrine injections serve to elevate the lesion by separating the mucosal layer from the underlying muscle layer of the colon, facilitating easier access for subsequent interventions. The procedure is performed under air insufflation, which helps to expand the colon and improve visualization by separating the mucosal folds. After the injections are administered, the endoscope is withdrawn, and a thorough inspection of the mucosal surfaces is conducted to check for any ulcerations, bleeding sites, strictures, or other abnormalities that may require further attention.