Defining “Screening Colonoscopy” 


Your insurance benefit is based on the reason why you are having the colonoscopy.

Screening (preventative) – the colonoscopy is performed on a patient who does not have symptoms or abnormal findings or known disease.

Diagnostic – the colonoscopy is performed on a patient to identify the cause of a symptom or abnormal finding or to evaluate a known disease (such as history of colon polyps found in a previous colonoscopy).

With respect to colon-cancer screening and prevention, the colonoscopy must be performed before symptoms arise, when the patient feels perfectly well. Cancers detected after symptoms develop are often advanced and incurable. Some insurers and the Affordable Care Act call screening exams a “preventative service.”

Government and private health plans typically provide different levels of benefit based on how a procedure is classified. This classification may determine if a procedure is covered at all, and if covered, it may determine the portion covered by the plan and the member’s deductible and copay responsibility.

Medicare and most private insurers cover a colonoscopy as a colon cancer screening benefit; however, the benefit varies substantially from insurance company to insurance company and even from policy to policy within a single insurance plan. We suggest that you contact your insurance company directly to determine the coverage provided by your insurance carrier.

Screening Benefits

Medicare allows a screening colonoscopy every 10 years for average-risk patients and every 2 years for high-risk patients. In most cases, you will not be advised to have a colonoscopy as frequently as every 2 years even if the benefit allows this.

You are considered high-risk if:

  • A close relative (sibling, parent or child) has had colon cancer or an adenomatous polyp
  • A personal history of colorectal cancer or adenomatous polyps Inflammatory bowel disease, such as Crohn’s or ulcerative colitis

Private insurance companies are not subject to Medicare payment rules and typically have established their own preferred policies and reporting instruction. Private health plans are now subject to regulation under the Affordable Care Act. If you have private insurance, we strongly recommend that you contact your insurance company directly, using the telephone number on your insurance ID card. Be ready to provide your plan numbers and the colonoscopy procedure code (45380) and diagnosis, which is the reason for your procedure, i.e., preventative screening (V76.51), history of polyps (V12.72), abdominal pain (789.07), rectal bleeding (569.3), etc.

If your insurance carrier has specific instructions for us with respect to the coding of our services, please communicate this information to our office in advance of your procedure. 

Consultations Prior to Colonoscopy

Dr. Dumois feels that an office visit prior to a procedure is necessary in order to most effectively obtain the information we need to provide safe and effective sedation and endoscopy care.

In order to provide you with a safe, effective, and comfortable procedure, we must have a complete understanding of your medical history, particularly in regard to any past procedures or operations that you may have had, medical problems that you are being treated for, drugs or over-the-counter remedies that you are taking, and any allergies or medication intolerances you may have.

This visit requires a separate charge from the procedure because the medical reimbursement system does not allow for “bundling” of these fees into a global procedure charge. Therefore, you will be expected to pay a specialist co-pay on the day of your consultation and follow-up appointments. This co-pay is usually found on the front of your insurance ID card.