Does 45386 require prior authorization?

No, 45386 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 45386?

Medicare facility rate: $187.38. Non-facility rate: $670.36. Work RVU: 3.68.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

3.68

Facility

$187.38

Non-Facility

$670.36

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.

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.
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.

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

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