Does 45331 require prior authorization?

No, 45331 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 45331?

Medicare facility rate: $66.80. Non-facility rate: $322.99. Work RVU: 1.11.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.11

Facility

$66.80

Non-Facility

$322.99

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
All services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.

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.
Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, or inadequate exam).

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

J05

A56632 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

L34005 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

CIGNA-A004 — Preventive Care Services - (A004)

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