45398
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.10
Facility
$209.42
Non-Facility
$902.49
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.
- Diagnostic colonoscopy is covered when determined to be reasonable and necessary in accordance with Local Coverage Determination L38812.
- Colonoscopy to evaluate an abnormality on other imaging (e.g., barium enema, CT, MRI, ultrasound, PET) likely to be clinically significant such as a filling defect or stricture.
- Colonoscopy for evaluation and excision of polyps detected by imaging or flexible sigmoidoscopy.
7 Active Policies
L33671 — Diagnostic Colonoscopy
J09
A55937 — Billing and Coding: Diagnostic Colonoscopy
J09
L38812 — Diagnostic Colonoscopy
J12
A58428 — Billing and Coding: Diagnostic Colonoscopy
J12
L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related Codes
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