What is the 2026 reimbursement for CPT 45380?

The national average payment for 45380 in 2026 (Non-Facility) is approximately $250.84, reflecting the -2.5% efficiency adjustment on the Work RVU.

How do I bill if a screening colonoscopy becomes a biopsy?

For Medicare, bill 45380 with Modifier PT. This tells Medicare the procedure started as a screening, allowing the patient's deductible to be waived. For commercial insurance, use Modifier 33.

What if the doctor cannot reach the cecum during the colonoscopy?

If the cecum is not reached, the procedure is considered 'incomplete.' You must append Modifier 53 (discontinued) or 52 (reduced services) and the reimbursement will be adjusted accordingly.

Can I bill 45380 and 45385 together?

Yes, if the biopsy (45380) is performed on a different lesion than the snare removal (45385). You should append Modifier 59 to the lesser-valued code (45380).

SpecialistBase2026 Compliant

CPT 45380

2026 Billing Guide

Colonoscopy with Biopsy

Reimbursement

$308.62

Threshold

N/A

2026 Status

Active

What is CPT Code 45380?

CPT 45380 is defined as: A diagnostic procedure using a flexible endoscope to examine the entire colon and rectum, with the performance of one or more biopsies. This code is used when tissue is removed for pathological examination but not for the removal of an entire polyp (which would use 45385 or 45384). It includes the use of forceps to take samples of the lining or specific lesions.

This code is primarily used for Specialist services. It falls under the category of Surgery / Digestive System and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.

2026 RVU Components

Relative Value Units (Non-Facility)

Standard Formula Applied

Work RVU

3.59

Physician Effort

PE (Non-Fac)

5.25

Practice Expense

Malpractice

0.4

Risk Factor

Total RVU

9.24

Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

2026 CMS Policy Intelligence

efficiency adjustment

Subject to -2.5% Efficiency Adjustment. CMS assumes that high-definition scopes and improved AI-assisted polyp detection have streamlined the interpretive and procedural work of colonoscopies.

conversion factor

Utilizes the 2026 Non-QP rate of $33.40.

site of service

Payment is significantly lower in the facility setting (POS 22/24) compared to the office (POS 11) because the facility bills its own 'Facility Fee' separately.

Administrative Framework

Global Period

000 (0 Days)

Place of Service

11 (Office)22 (Outpatient Hospital)24 (ASC)

NCCI Exclusions

Do not bill with:4537845384453854533099211-99215

Key Modifiers

33Preventive service. Used for commercial payers to indicate the service should have no cost-sharing under the ACA.

53Discontinued procedure. Used if the colonoscopy cannot be completed to the cecum due to poor prep or patient safety.

Operational Requirements

extent of exam

To bill a full colonoscopy, the endoscope must reach the cecum or the ileocolonic anastomosis. If it does not reach the cecum, bill with Modifier 53 or 52.

biopsy vs removal

Use 45380 for tissue samples. If the entire lesion/polyp is removed via snare or forceps, use 45385 or 45384. You cannot bill 45380 for 'cold' forceps removal of a small polyp; that is considered removal, not biopsy.

sedation billing

Moderate sedation (99152-99153) or Anesthesia (00812) is typically billed separately depending on who provides the service.

bowel prep documentation

The quality of the bowel preparation (e.g., Boston Bowel Preparation Scale) must be documented in the procedure report.

Compliance Checklist

Detailed time tracking (cumulative for the month).

Specific clinical decision-making documentation.

Electronic care plan availability and access log.

Audit Defense

No specific audit defense elements defined.

2026 Update

Work RVU reduced by 2.5% efficiency adjustment. Use PT modifier for Medicare screening-to-diagnostic conversions.

Common Clinical Scenarios

No clinical examples provided.

Target Specialties & Utilization

GastroenterologyGeneral Surgery

Typical Clinical Indications (ICD-10)

K63.5 (Polyp of colon)D12.6 (Benign neoplasm of colon, unspecified)K52.9 (Noninfective gastroenteritis and colitis, unspecified)

Frequently Asked Questions

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Official Data Provider: CMS Physician Fee Schedule (2026)