Does 45378 require prior authorization?

No, 45378 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 45378?

Medicare facility rate: $164.67. Non-facility rate: $378.10. Work RVU: 3.18.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

3.18

Facility

$164.67

Non-Facility

$378.10

Medical record must document the extenuating/unforeseen circumstances and the specific inability to advance the colonoscope to the cecum or colon–small intestine anastomosis to support billing as an incomplete procedure.
Submit the failed colonoscopy on the claim using CPT 45378, HCPCS G0105 or G0121, or CPT 44388 (stoma) with modifier -53 appended.
If a covered colonoscopy is later attempted and completed, submit the completed procedure claim; Medicare will pay for the completed colonoscopy according to its standard payment methodology provided all coverage conditions are met.
The submitted CPT/HCPCS code must accurately describe the service performed.

A colonoscopy attempt that cannot be completed because of extenuating/unforeseen circumstances (e.g., inability to advance the colonoscope to the cecum or to a colon–small intestine anastomosis) is considered an incomplete/failed colonoscopy.
Policy applies to both screening and diagnostic colonoscopies.
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.

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

J05

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L33671 — Diagnostic Colonoscopy

J09

A55937 — Billing and Coding: Diagnostic Colonoscopy

J09

L38812 — Diagnostic Colonoscopy

Ask Verity about documentation requirements, denial risks, or coverage in your state.