Colonoscopy insurance

What you need to know before a colonoscopy

The Affordable Care Act (ACA), passed in March 2010, covers many preventive services at no cost to you, such as a colonoscopy for colorectal cancer screening. People having a colonoscopy fall into three groups and strict coding guidelines are used to decide which one you are in. These guidelines may keep your procedure from being 100 percent covered by your insurance carrier. This can happen even if your primary care physician referred you for a “screening” colonoscopy. A personal or family history may be why your colonoscopy is labeled a diagnostic or surveillance colonoscopy. This is decided by each health insurance policy.

Colonoscopy types

There are three types of colonoscopies. Insurance companies differ in how they pay for them.

Diagnostic/therapeutic colonoscopy
This is done to find the cause of a medical problem, such as gastrointestinal symptoms, colon polyps, or gastrointestinal disease. (CPT Code: 45380 – See option 1 below)
Surveillance/high-risk colonoscopy screening
This is done when you have a personal history of Crohns’ Disease, Ulcerative Colitis, or a personal or direct relative with colon polyps, and/or colon cancer. This is not done because you have gastrointestinal symptoms. You will need to have colonoscopy more often than other people (often every 2 to 5 years). This type may be reimbursed by some insurance carriers as if you were having a diagnostic colonoscopy. (CPT Code: 45378 – See option 2 below)
Preventive/average risk colonoscopy screening
This is part of the Affordable Care Act. This is done when you do not have gastrointestinal symptoms, are 50 years old or older, and do not have a personal history of gastrointestinal disease, colon polyps, and/or cancer. People in this group have not had a colonoscopy within the last 10 years. (CPT Code: 45378 – See option 3 below)

The type of colonoscopy can change during the procedure. We cannot be sure your procedure will be billed as one type or the other. You need to check with your insurance company to find out how they pay for each type. This will help you will know how much you will have to pay.

To find out the type of your colonoscopy and estimate insurance coverage, call your insurance company’s customer service line and ask:

How will my coverage reimburse for each of these CPT codes and associated diagnoses?

a. CPT Code: 45380 Diagnosis: Clinical findings such as polyp (k63.5)
b. CPT Code: 45378 Diagnosis: Z86.010 (personal history)
c. CPT Code: 45378 Diagnosis: Z12.11 and/or Z80.0 (screening or family history)

Will the claim be processed as:

  1. Diagnostic/therapeutic/medical
  2. Surveillance
  3. Preventive (routine/screening)

Will this colonoscopy be paid by the insurance company at 100% as defined by the ACA?

Yes or no

If I have a preventive (screening) procedure, does my insurance plan have age, frequency, or personal/family history limitations for my colonoscopy?

Such as one every ten years over the age of 50, one every two years for personal history of polyps starting at age 45, etc.

Yes or no

If yes, list limitations here: _________________________________

If my doctor removes a polyp, will this change my out-of-pocket cost?

Does a biopsy or polyp removal change a screening benefit to a medical benefit? This would mean more out-of-pocket costs. This policy changes by carrier.

Yes or no

After talking with your insurance company, please call UI Health Care’s Patient Financial Services at 866-452-8506 if you have more questions or concerns. You can also call to set up a payment plan.

Billing and coding

We code and bill services based on your medical record documentation. We cannot change the coding of your office visit or procedures.

Deductible/copays

We will do our best to get eligibility, deductible, and precertification requirements from your insurance company for the services provided and billed by UI Health Care. We will send you a letter or call if you need to make a payment before your procedure. You still need to check with your insurance company to learn about any deductibles, co-pays, or co-insurance you may owe. You are responsible for all charges due to treatment given by UI Health Care.

Frequently asked questions about colonoscopies and insurance

Can the doctor change, add, or delete my diagnosis so my procedure can be billed as a preventive screening?
No. The medical record has the information you have given and the results of your doctor’s assessment. After the medical record is documented it becomes a binding, legal document and cannot be changed for better insurance coverage.

If an error in the medical record is noticed, such as date of birth, medicine dose, or health history, then you may ask for a correction or amendment by calling the doctor’s office.
What if my insurance company tells me UI Health Care can change, add, or delete a CPT or diagnosis code?
If you are told this, call UI Health Care’s Billing Office at 866-393-4605. They will start a coding review of your medical record. To better let us help you, please write down:
  • The date of the call to your insurance
  • The name of the insurance representative you talked with and their phone number
  • A reference number
Is an Upper Endoscopy (EGD) part of the ACA?
No. People will need to pay their deductible and copay as stated in your health insurance policy.
Last reviewed: 
January 2018

Interested in using our health content?