45393
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.56
Facility
$218.44
Non-Facility
$218.44
Documentation Required
- 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.
Key Coverage Criteria
- Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
- 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.
- A colonoscopy may be billed when a sigmoidoscope is used only if the bowel is sufficiently short that the entire colon can be examined and this fact is clearly documented in the clinical record.
- An incomplete colonoscopy (inability to advance the colonoscope to the cecum or colon‑small intestine anastomosis due to unforeseen circumstances) is billed using codes 44388, 45378, G0105 or G0121 with modifier -53.
- When the colonoscopy procedure is unusual or difficult, report modifier -22 (unusual procedural services) on the claim.
11 Active Policies
L33671 — Diagnostic Colonoscopy
J09
A55937 — Billing and Coding: Diagnostic Colonoscopy
J09
A58428 — Billing and Coding: Diagnostic Colonoscopy
J12
L38812 — Diagnostic Colonoscopy
J12
L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.