Colonoscopy, flexible; diagnostic
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Colonoscopy diagnostic billed when screening colonoscopy appropriate
Very Common45378 (colonoscopy diagnostic) vs screening colonoscopy (G0105, G0121) - different codes and coverage. If patient asymptomatic average-risk screening, use G-codes. If symptoms, surveillance, or high-risk, use 45378. Wrong code selection causes denials - screening colonoscopy often 100% covered, diagnostic has copay/deductible.
Common Causes
- • Screening colonoscopy billed as diagnostic 45378 - should use G0121
- • Polyp found during screening - still bill screening code, not diagnostic
- • Patient had prior polyps (surveillance) - that's diagnostic 45378, but must document surveillance indication
Resolution Strategy
Determine appropriate code: Asymptomatic average-risk screening (age 45+) = G0121, High-risk screening (family history, prior polyps within 10 years, IBD) = G0105, Symptoms or surveillance post-polypectomy = 45378 diagnostic. If screening billed as diagnostic, rebill with G-code. If polyp removed during screening, add polypectomy code but keep screening primary code. Cannot change diagnostic to screening without documentation supporting screening indication.
💬 Plain Language Explanation
What this means
This is a colonoscopy - a procedure where a doctor uses a flexible tube with a camera to examine the inside of your colon (large intestine).
Why you might see this
This is a common screening test for colon cancer and other colon problems. Your doctor likely ordered this as a routine screening (usually starting at age 45) or to investigate colon symptoms.
Common context
Common screening test for colon cancer, usually done every 10 years starting at age 45, or to investigate colon symptoms.
What to ask your provider
"'What did the colonoscopy show? Were there any polyps or abnormalities found?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
For diagnostic colonoscopy to evaluate colon and rectum without therapeutic intervention
Common Scenarios
Documentation Requirements
- Indication for colonoscopy
- Extent of examination (cecum reached, ileum intubated)
- Quality of bowel preparation
- Findings in each colonic segment
- Withdrawal time and technique
Coding Guidelines
Common Modifiers
Bundling Rules
- Includes inspection of entire colon
- Includes terminal ileum intubation if performed
- Biopsy bundled when performed same session
- Polypectomy requires separate code
- Upper endoscopy coded separately if performed same session
Exclusions
- 45380 (colonoscopy with biopsy)
- 45385 (colonoscopy with polypectomy)
- 45381 (colonoscopy with directed injection)
- 45382 (colonoscopy with control of bleeding)
Coding Notes
Clinical scenarios
- Indication for colonoscopy
- Extent of examination (cecum reached, ileum intubated)
- Quality of bowel preparation
- Indication for colonoscopy
- Extent of examination (cecum reached, ileum intubated)
- Quality of bowel preparation
- Indication for colonoscopy
- Extent of examination (cecum reached, ileum intubated)
- Quality of bowel preparation
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Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
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Ask a QuestionFrequently Asked Questions
CPT 45378 is the billing code for "Colonoscopy, flexible; diagnostic". For diagnostic colonoscopy to evaluate colon and rectum without therapeutic intervention
Medicare pays approximately $327.67 for CPT 45378 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 45378 has a total RVU of 7.55, broken down as: Work RVU 2.50, Practice Expense RVU 4.80, and Malpractice RVU 0.25. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 45378 is "Colonoscopy diagnostic billed when screening colonoscopy appropriate". 45378 (colonoscopy diagnostic) vs screening colonoscopy (G0105, G0121) - different codes and coverage. If patient asymptomatic average-risk screening, use G-codes. If symptoms, surveillance, or high-risk, use 45378. Wrong code selection causes denials - screening colonoscopy often 100% covered, diagnostic has copay/deductible. Common causes include: Screening colonoscopy billed as diagnostic 45378 - should use G0121; Polyp found during screening - still bill screening code, not diagnostic. Appeal success rate is approximately 10-30%.
Key documentation requirements for CPT 45378 include: Indication for colonoscopy; Extent of examination (cecum reached, ileum intubated); Quality of bowel preparation; Findings in each colonic segment. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 45378: Includes inspection of entire colon. Includes terminal ileum intubation if performed Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 45378 include: 52 (Reduced services if procedure not completed), 53 (Discontinued procedure due to patient condition), 33 (Preventive service when performed for screening). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 45378 is 15-30 minutes typical procedure time. Time-based codes require documentation of the actual time spent providing the service.