44408
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.04
Facility
$203.75
Non-Facility
$203.75
Documentation Required
- The submitted CPT/HCPCS code must accurately describe the service performed.
- All documentation must be maintained in the patient medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
Key Coverage Criteria
- Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
- Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
- Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
- A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
- Diagnostic colonoscopy is covered when determined to be reasonable and necessary in accordance with Local Coverage Determination L38812.
- Colonoscopy to evaluate an abnormality on other imaging (e.g., barium enema, CT, MRI, ultrasound, PET) likely to be clinically significant such as a filling defect or stricture.
7 Active Policies
L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic
J05
A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic
J05
A55937 — Billing and Coding: Diagnostic Colonoscopy
J09
L33671 — Diagnostic Colonoscopy
J09
A58428 — Billing and Coding: Diagnostic Colonoscopy
Related Codes
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