CPT 45398: Colonoscopy with Band Ligation, Billing, Coding & Documentation in 2026
How 45398 (band ligation) compares to 45381 (submucosal injection) and other same-family colonoscopy codes.
Correction Note A note on this code: CPT 45398 is sometimes confused with colonoscopy submucosal injection coding. The current CPT descriptor for 45398 is "Colonoscopy, flexible; with band ligation(s) (e.g., hemorrhoids)." Submucosal injection during colonoscopy is reported under CPT 45381. This guide covers CPT 45398 accurately and explains how it relates to 45381 and other same-session colonoscopy codes. |
A patient with symptomatic internal hemorrhoids undergoes a colonoscopy, and the physician bands the hemorrhoids during the same encounter. The clinical note reads clearly, and the claim still runs into trouble -- because band ligation and diagnostic colonoscopy don't automatically stack the way the billing team assumed, and NCCI has specific rules about what's bundled into what.
CPT 45398 covers a specific therapeutic colonoscopy service, frequently mixed up with other same-family codes -- including the submucosal injection code nearby in the CPT book. Getting it right depends on matching the code to the documented technique and knowing where NCCI already answered the bundling question.
This guide covers what CPT 45398 represents, how it compares to related colonoscopy codes -- including submucosal injection under CPT 45381 -- what documentation should show, and where these claims run into denials in 2026.
CPT 45398 at a Glance
Element | Detail |
CPT Code | 45398 |
Procedure | Colonoscopy, flexible; with band ligation(s) (e.g., hemorrhoids) |
Main billing issue | Correctly identifying band ligation vs. other same-session colonoscopy techniques |
Documentation focus | Technique used, findings, and medical necessity for the therapeutic intervention |
Payer review | Multiple-procedure and NCCI rules for colonoscopy code combinations vary and should be checked |
What Does CPT 45398 Represent?
CPT 45398 describes a flexible colonoscopy during which the physician performs band ligation -- most commonly for internal hemorrhoids. A flexible scope is advanced through the colon, the affected tissue is identified, and a band is applied at its base to cut off blood supply, causing the tissue to eventually slough off. This code applies specifically when band ligation is the therapeutic intervention performed. It shouldn't be selected simply because a colonoscopy was performed and some intervention took place -- the note needs to describe band ligation specifically, not injection, biopsy, or snare removal.
When Is CPT 45398 Appropriate?
Documentation supports CPT 45398 when the operative note describes a colonoscopy during which band ligation was performed on identified tissue -- typically internal hemorrhoids. The presence of hemorrhoids alone doesn't determine the code; the record needs to show ligation, specifically, was the technique used. If the note instead describes submucosal injection, biopsy, forceps removal, or snare removal, a different code in the 45379-45398 family applies. Code selection follows the documented service, not an assumption based on the general reason for the colonoscopy.
CPT 45398 vs. Related Colonoscopy Services
Several codes in the same family describe different therapeutic techniques performed during a flexible colonoscopy. Selecting among them depends on which technique the operative note actually documents:
CPT Code | Technique | Key Difference | Documentation Focus |
45398 | Band ligation(s) | Ligates tissue (e.g., hemorrhoids) to cut off blood supply | Confirm band ligation is the technique described |
45381 | Directed submucosal injection(s), any substance | Injects a substance beneath the mucosa -- a different technique entirely | Confirm injection, not ligation, was performed |
45380 | Biopsy, single or multiple | Tissue sampling, not therapeutic removal or ligation | Confirm biopsy forceps and specimen collection |
45384 | Removal of tumor(s)/polyp(s) by hot biopsy forceps | Removal technique using hot forceps | Confirm the specific removal method used |
45385 | Removal of tumor(s)/polyp(s) by snare technique | Removal technique using a wire snare | Confirm snare technique, distinct from forceps or ligation |
45382 | Control of bleeding, any method | Addresses active bleeding, not a planned therapeutic technique | Confirm the clinical circumstance was bleeding control |
Note: The diagnosis (e.g., hemorrhoids, polyps) narrows the clinical picture, but the technique documented in the operative note is what determines the code. A colonoscopy performed for hemorrhoids could still result in 45381 or another code if the physician injected rather than banded.
Same-Session and Multiple-Procedure Review
GI practices frequently perform more than one technique during a single colonoscopy -- a biopsy alongside band ligation, for example, or bleeding control alongside a planned intervention. Whether each service is separately reportable depends on what was actually performed, current CPT guidance, applicable NCCI edits, and the payer's rules. The base diagnostic colonoscopy code (45378) is generally a bundled component when a therapeutic code from the same family is also reported at the same session -- it isn't typically billed as a separate line alongside 45398. Beyond that baseline, whether two therapeutic techniques at the same session are both separately reportable depends on the specific code pair and current NCCI edit status, verified directly rather than assumed. A modifier should never be added simply to bypass an edit.
Does This Procedure Note Support CPT 45398?
☐ Does the report clearly identify the colonoscopy performed?
☐ Does it specifically document band ligation as the technique used?
☐ Is the tissue treated (e.g., internal hemorrhoids) clearly identified?
☐ Is the clinical reason for the procedure documented?
☐ Does the diagnosis support medical necessity?
☐ Are other procedures performed during the same encounter clearly documented?
☐ Have applicable payer requirements been checked?
☐ Have relevant NCCI/claim edits been reviewed?
Before You Submit If the documentation cannot answer these questions, pause before submitting the claim. |
CPT 45398 Documentation Checklist
☐ Indication for the colonoscopy
☐ Relevant clinical history
☐ Medical necessity for the intervention
☐ Colonoscopy procedure documentation
☐ Band ligation technique specifically documented
☐ Location/site of the tissue treated
☐ Details distinguishing this service from other techniques (injection, biopsy, snare)
☐ Physician interpretation/report and findings
☐ Diagnosis coding support
☐ Authorization requirements where applicable
☐ Payer-specific documentation requirements
☐ Modifiers, when legitimately supported
Note: Documentation requirements can vary by payer. This is a review framework, not a universal checklist.
Medical Necessity & Diagnosis Coding
The diagnosis supports medical necessity. The documented service supports the procedure code. Treating these as the same thing is how a claim ends up with a code that doesn't match what was actually performed. A billing team shouldn't select CPT 45398 simply because the diagnosis mentions hemorrhoids -- the note needs to independently confirm band ligation was the technique used. Diagnosis coding should reflect documented history and findings and align with the payer's coverage criteria; verify specific ICD-10-CM codes against the current code set rather than assuming from a general condition category.
Medicare & Commercial Payer Considerations
Coverage and payment for CPT 45398 depend on the applicable payer's policy -- Medicare coverage isn't automatic simply because the code is valid, and MACs can apply their own coverage and documentation guidance. Commercial payers maintain separate medical policies, contractual terms, and claim-editing rules that may differ from Medicare's and from each other. Authorization requirements, if any, also vary by payer, plan, and clinical circumstance. Verify the applicable policy directly rather than assuming one payer's rules carry over to another.
Modifiers & NCCI
Modifier use for CPT 45398 depends on the actual circumstances. Where multiple procedures are performed during the same colonoscopy, modifier review may be necessary to reflect genuinely distinct services -- but only when documentation supports it and current NCCI and payer-specific edits allow separate reporting. Never apply a modifier simply because a claim edit is blocking payment. Verify current NCCI guidance and the payer's bundling rules for the specific code combination first.
10 CPT 45398 Billing Mistakes to Watch For
Mistake | Why It Matters |
Using outdated CPT information | Confirm the current descriptor before coding, not a remembered version |
Coding from the diagnosis instead of the documented procedure | Hemorrhoids in the diagnosis doesn't confirm ligation was performed |
Assuming any intervention supports CPT 45398 | The note must specifically describe band ligation |
Weak procedure-note documentation | A vague note can't support any specific technique-based code |
Ignoring the exact service performed | Confirm ligation vs. injection vs. biopsy vs. snare before coding |
Failing to review other procedures performed | Multiple techniques in one session need individual review |
Applying unsupported modifiers | A modifier must reflect a genuinely distinct, documented service |
Ignoring NCCI edits | Bundling rules for colonoscopy code combinations are specific and should be checked |
Failing to check payer-specific requirements | Coverage and documentation rules vary by payer |
Submitting without a final documentation and claim review | A last check catches mismatches before the payer does |
60-Second CPT 45398 Claim Check
☐ Procedure verified
☐ Technique (band ligation) documented
☐ Medical necessity supported
☐ Diagnosis reviewed
☐ Related procedures reviewed
☐ Payer requirements checked
☐ NCCI/claim edits reviewed
☐ Modifiers supported
60-Second Claim Check If one answer is uncertain, review before submission. |
Spot the Billing Problem
A fictional gastroenterology practice performs a colonoscopy involving band ligation. The billing team has CPT 45398 ready to submit, but the operative note doesn't clearly state which tissue was ligated or confirm the technique used, beyond a general note that "the area was treated."
Would you submit the claim, or stop for documentation review?
Note: Stop for review. Without the note confirming band ligation specifically -- and identifying what was treated -- the claim risks a documentation mismatch even if the clinical work was appropriate. (This is a fictional, educational example; Sirius Solutions Global did not handle this case.)
Spot the Difference: Two Documentation Examples
Note A: "Colonoscopy performed. Area treated. Patient tolerated procedure well."
Note B: "Colonoscopy advanced to cecum. Internal hemorrhoids identified at [location]. Band ligation performed on [number] hemorrhoids using [device]. Post-procedure findings documented."
Which note gives the billing team stronger support for claim review, and why?
Note: Note B. It identifies the technique (band ligation), the tissue treated, the location, and post-procedure findings -- everything needed to confirm CPT 45398 is the correct code. Note A doesn't specify what was done or to what, leaving the coder to guess.
What Actually Affects Payment?
A CPT code identifies the service. It does not guarantee a specific payment amount. Payment depends on the payer, Medicare status, locality, contract, coverage, medical necessity, coding accuracy, documentation, claim edits, and modifier use where applicable. Verify the current Medicare rate for your locality through the CMS Physician Fee Schedule lookup tool, and commercial allowed amounts against the contract. Sirius Solutions Global does not publish or promise a specific reimbursement figure.
CPT 45398 Billing Workflow
Stage | What Happens Here |
Clinical Indication | The reason for the colonoscopy is established and documented |
Colonoscopy Performed | Band ligation and any other techniques are carried out |
Procedure Documentation | The note specifies technique, tissue treated, and findings |
CPT Review | The code is matched to the documented technique, not the diagnosis |
Diagnosis & Medical Necessity | Diagnosis coding is confirmed against the documented condition |
Payer / NCCI Review | Bundling rules and payer-specific requirements are checked |
Claim Submission | A complete, internally consistent claim goes out |
Payment or Denial | The remittance is reviewed against expectations |
A/R Follow-Up | Denials and underpayments are worked based on the actual reason |
Reconciliation | The account closes only once the record checks out |
How Strong Is Your CPT 45398 Billing Workflow?
☐ Do you verify current CPT updates before coding?
☐ Does your billing team review the procedure note before assigning a code?
☐ Are related procedures performed during the same session reviewed together?
☐ Are payer requirements checked before submission?
☐ Are denials and underpayments analyzed for root cause, not just resubmitted?
Note: Several "No" answers may be a sign that the workflow deserves a closer review.
About Sirius Solutions Global
Sirius Solutions Global is a Dallas-based Revenue Cycle Management company supporting healthcare organizations with medical billing and RCM, claims management, denial management, A/R follow-up, payment posting, billing audits, credentialing and provider enrollment, prior authorization support, and front desk/virtual assistant support. The goal for a code like 45398 is the same as any GI billing question: match the code to the documented technique, keep documentation and diagnosis consistent, and follow up on denials by root cause.
Frequently Asked Questions
What is CPT 45398?
CPT 45398 describes a flexible colonoscopy with band ligation, most commonly performed for internal hemorrhoids.
What procedure does CPT 45398 describe?
The physician advances a flexible colonoscope, identifies the target tissue, and applies a band at its base to cut off blood supply.
Is CPT 45398 the code for submucosal injection during colonoscopy?
No. Submucosal injection is reported under CPT 45381. CPT 45398 is specifically for band ligation.
What documentation supports CPT 45398?
An operative note specifically documenting band ligation as the technique, the tissue treated, location, and findings.
How is CPT 45398 different from other colonoscopy codes?
It's distinguished by technique: 45381 is injection, 45380 is biopsy, 45384/45385 are removal by forceps or snare, and 45398 is band ligation.
Can multiple procedures be reported during the same colonoscopy?
Sometimes, if the services are genuinely distinct and documented separately. Current NCCI edits and payer policy should be checked before reporting more than one.
Does Medicare cover CPT 45398?
Coverage depends on medical necessity, documentation, and the applicable Medicare or MAC policy -- it isn't automatic or universal.
Are modifiers required for CPT 45398?
Not universally. A modifier applies only when documentation supports a genuinely distinct circumstance, verified against current NCCI and payer guidance.
What can cause a CPT 45398 claim denial?
Common causes include a technique/code mismatch, weak documentation, unreviewed multiple-procedure bundling, or unmet payer-specific requirements.
How can an RCM company help with CPT 45398 billing?
By reviewing documentation against code selection, checking NCCI and payer edits, and following up on denials and underpayments based on root cause.
Sources / References
• AMA -- CPT code set -- current descriptors for 45378-45398 colonoscopy family codes
• American Society for Gastrointestinal Endoscopy (ASGE) -- Colonoscopy CPT coding reference sheets
• CMS -- Medicare Physician Fee Schedule lookup tool and National Correct Coding Initiative (NCCI) resources
• Applicable Medicare Administrative Contractor (MAC) -- Local Coverage Determinations for colonoscopy procedures
Disclaimer
This article is provided for general educational and informational purposes and does not replace current CPT instructions, payer policies, Medicare guidance, or professional coding advice. Coding, coverage, and reimbursement requirements can change and vary by payer, MAC, locality, and clinical circumstance -- verify current requirements applicable to the specific claim and payer before submission. Sirius Solutions Global makes no guarantee regarding claim approval, coverage, or reimbursement outcomes. CPT is a registered trademark of the American Medical Association.
