Does 45385 require prior authorization?

No, 45385 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 45385?

Medicare facility rate: $223.45. Non-facility rate: $500.01. Work RVU: 4.46.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

4.46

Facility

$223.45

Non-Facility

$500.01

Medical record documentation must demonstrate the specific criteria for use of the NCCI-associated modifier (e.g., description of separate anatomic sites, separate lesions, separate incisions/excisions, or evidence of separate patient encounters).
When using modifier 59 to report two procedures on the same date of service, include operative notes or encounter notes that specifically justify separate sites or separate encounters; different diagnoses alone are insufficient documentation.
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.

Append CPT modifier 59 when two or more procedures/services that are not normally reported together are performed at different anatomic sites (different organs or different lesions within the same organ).
Append CPT modifier 59 when procedures/services are performed during different patient encounters or sessions (separate encounters) even if on the same date of service.
Append CPT modifier 59 when procedures/services involve a separate incision/excision, a separate lesion, or a different area of injury in extensive injuries.
Use CPT modifier 59 to report two codes of an NCCI edit together only when no other NCCI-associated modifier more appropriately describes the relationship between the procedures.
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.

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.