A colonoscopy is a screening test that can help detect colon cancer or pre-cancer. The earlier signs of colon cancer are detected, the easier it is to prevent or treat the disease.
A screening test is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure. As part of the Affordable Care Act (ACA), Medicare and most third-party payors are required to cover services given an A or B rating by the U.S. Preventive Services Task Force (USPSTF) without a co-pay or deductible, but the correct CPT and ICD-10-CM codes must be submitted to trigger coverage at 100% for the patient.
Diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign or symptom (such as abdominal pain, bleeding, diarrhea, etc.). Medicare and most commercial payors do not waive the co-pay and deductible when the intent of the visit is to perform a diagnostic colonoscopy.
The CPT code for a colonoscopy without biopsy or other interventions is 45378.
This code is used for commercial and Medicaid patients.
The HCPCS code for a screening colonoscopy for a Medicare patient is G0105.
The ICD-10-CM diagnosis code for a screening colonoscopy is Z12.11. This code can be used for reimbursement purposes.
Other CPT codes for colonoscopies include:
For Medicare beneficiaries who choose colonoscopy as their colorectal cancer screening, use Healthcare Common Procedural Coding System (HCPCS) code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk) as appropriate. CMS developed the HCPCS codes to differentiate between screening and diagnostic colonoscopies in the Medicare population. If polyps are removed, use the appropriate CPT code listed above and add modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) to each CPT code for Medicare. If modifier PT is not added to the CPT code submitted on the Medicare claim, the colonoscopy with polypectomy will not be recognized as a screening service and the patient will be inappropriately billed.
Medicare beneficiaries without high risk factors are eligible for screening colonoscopy every 10 years. Beneficiaries at high risk for developing colorectal cancer are eligible once every 24 months. Medicare considers an individual at high risk for developing colorectal cancer as one who has one or more of the following:
Billing and Coding: Diagnostic and Therapeutic Colonoscopy
CPT codes
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A screening test is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure. As part of the Affordable Care Act (ACA), Medicare and most third-party payors are required to cover services given an A or B rating by the U.S. Preventive Services Task Force (USPSTF) without a co-pay or deductible, but the correct CPT and ICD-10-CM codes must be submitted to trigger coverage at 100% for the patient.
Diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign or symptom (such as abdominal pain, bleeding, diarrhea, etc.). Medicare and most commercial payors do not waive the co-pay and deductible when the intent of the visit is to perform a diagnostic colonoscopy.
The CPT code for a colonoscopy without biopsy or other interventions is 45378.
This code is used for commercial and Medicaid patients.
The HCPCS code for a screening colonoscopy for a Medicare patient is G0105.
The ICD-10-CM diagnosis code for a screening colonoscopy is Z12.11. This code can be used for reimbursement purposes.
Other CPT codes for colonoscopies include:
- 45380 – Colonoscopy with biopsy
- 45381 – Colonoscopy with directed submucosal injection
- 45382 – Colonoscopy with control of bleeding
- 45380 – Colonoscopy, flexible; with biopsy, single or multiple
- 45384 – Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
- 45385 – Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
- 45388 – Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
For Medicare beneficiaries who choose colonoscopy as their colorectal cancer screening, use Healthcare Common Procedural Coding System (HCPCS) code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk) as appropriate. CMS developed the HCPCS codes to differentiate between screening and diagnostic colonoscopies in the Medicare population. If polyps are removed, use the appropriate CPT code listed above and add modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) to each CPT code for Medicare. If modifier PT is not added to the CPT code submitted on the Medicare claim, the colonoscopy with polypectomy will not be recognized as a screening service and the patient will be inappropriately billed.
Medicare beneficiaries without high risk factors are eligible for screening colonoscopy every 10 years. Beneficiaries at high risk for developing colorectal cancer are eligible once every 24 months. Medicare considers an individual at high risk for developing colorectal cancer as one who has one or more of the following:
- A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp.
- A family history of familial adenomatous polyposis.
- A family history of hereditary nonpolyposis colorectal cancer.
- A personal history of adenomatous polyps.
- A personal history of colorectal cancer.
- Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.
Coding FAQ - Screening Colonoscopy
We’ve compiled answers to common coding questions many practices have for screening colonoscopies, including coding modifiers and complex cases.
gastro.org
Billing and Coding: Diagnostic and Therapeutic Colonoscopy
CPT codes
| Code | Description |
|---|---|
| 44388 | COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) |
| 44389 | COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE |
| 44390 | COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF FOREIGN BODY(S) |
| 44391 | COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING, ANY METHOD |
| 44392 | COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS |
| 44394 | COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE |
| 44401 | COLONOSCOPY THROUGH STOMA; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE-AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) |
| 44402 | COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC STENT PLACEMENT (INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) |
| 44404 | COLONOSCOPY THROUGH STOMA; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE |
| 44405 | COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC BALLOON DILATION |
| 44406 | COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, LIMITED TO THE SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM AND ADJACENT STRUCTURES |
| 44407 | COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM AND ADJACENT STRUCTURES |
| 45378 | COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) |
| 45379 | COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S) |
| 45380 | COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE |
| 45381 | COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE |
| 45382 | COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD |
| 45384 | COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS |
| 45385 | COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE |
| 45386 | COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION |
| 45388 | COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) |
| 45389 | COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC STENT PLACEMENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) |
| 45391 | COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES |
| 45392 | COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES |
| 45393 | COLONOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED |
Article - Billing and Coding: Diagnostic and Therapeutic Colonoscopy (A57342)
Use this page to view details for the Local Coverage Article for billing and coding: diagnostic and therapeutic colonoscopy.
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