Does 45381 require prior authorization?

No, 45381 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 45381?

Medicare facility rate: $177.69. Non-facility rate: $490.33. Work RVU: 3.47.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

3.47

Facility

$177.69

Non-Facility

$490.33

Select the CPT code that accurately describes the diagnostic/therapeutic procedure that was performed or attempted during the colonoscopy.
Append the -PT modifier to the selected CPT code to indicate a screening colonoscopy was converted to a diagnostic or therapeutic procedure.
Use an appropriate ICD-10 diagnosis code indicating the procedure was a screening (example: Z80.0) when submitting the claim for a converted screening colonoscopy.
Document clinical findings in the medical record that demonstrate the screening colonoscopy was converted to diagnostic/therapeutic (e.g., description of encountered pathology and performed intervention).

If a screening colonoscopy encounters pathology that necessitates intervention converting it to a diagnostic or therapeutic colonoscopy, bill using the appropriate diagnostic/therapeutic CPT code appended with the -PT modifier and an appropriate screening ICD-10 diagnosis.
When beneficiaries are at high risk for colorectal malignancy, an ICD-10 screening code such as Z80.0 (family history of malignant neoplasm of digestive organs) may be used to indicate the procedure was a screening converted to diagnostic/therapeutic.
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

A55937 — Billing and Coding: Diagnostic Colonoscopy

J09

L33671 — Diagnostic Colonoscopy

J09

L38812 — Diagnostic Colonoscopy

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