CurrentBlue KCPolicy POL-PP-216

Gastrointestinal Endoscopies and Related Services

Payment and coding guidance for gastrointestinal endoscopic procedures (colonoscopy, EGD, ERCP, sigmoidoscopy, small intestinal pouch endoscopy) affecting professional and facility providers under Blue KC lines of business.

Policy Summary

PayerBlue KC

PolicyGastrointestinal Endoscopies and Related Services

Policy CodePolicy POL-PP-216

Change TypeClarification and correction

Effective Date08/09/2022

Next Review Date08/09/2026

Key ActionConfirm member eligibility, benefits, and any applicable limits; contact Blue KC provider hotlines for coverage confirmation.

SourceLink

POLICY UPDATE CHANGES

Information added on colonoscopy anesthesia codes 00811 and 00812 and payment for recontracted/newly contracted providers performing multiple endoscopies within the same family.

Codes were corrected to state that a diagnostic or screening endoscopy is included as part of a surgical endoscopic procedure and should not be separately reported (example: 45378 included as part of 45379-45398).

Version 6policy version

08/09/2026next review

Commercial & MAlines of business

CPT rangescoding overview

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Endoscopy Coverage and Billing Rules

Endoscopy coverage and billing rules

Payment and reporting rules for screening, diagnostic, and therapeutic endoscopy services.

Screening colonoscopy performed on an asymptomatic person should be identified with modifier 33; finding a polyp or cancer does not change the screening intent.

When the primary purpose of the service is an evidence-based preventive service (USPSTF A or B) or other mandated preventive service, identify the service with modifier 33; do not use modifier 33 for separately reported services specifically identified as preventive.

A diagnostic or screening endoscopy is included as part of a surgical endoscopic procedure and should not be separately reported (example: 45378 is included as part of codes 45379 through 45398).

An endoscopic biopsy performed at the same surgical site as an excision or removal (e.g., 43202 with 43216) is included in the excision/removal code and should not be reported separately.

When an endoscopic biopsy is performed on a separate surgical site unrelated to the excision/removal, the biopsy may be considered for separate payment when billed with modifier 59; the medical record must document the different surgical sites.

When a single endoscopic technique is performed on separate surgical sites, report the code only once (e.g., multiple esophageal polyps removed by snare — code 43217 reported once).

If different endoscopic techniques are performed on separate sites, multiple endoscopy codes may be reported (example: 43216 and 43217 reported when different techniques are used at different sites).

Distinct procedures example

CPT 45385 and CPT 45380 may be submitted together if the two procedures are performed on separate lesions; report modifier 59 or XS to indicate the procedure was distinct or independent.
Use modifier 59 or XS to indicate distinct/independent procedures when submitting colonoscopy with biopsies and snare removal performed on separate lesions (e.g., 45385 and 45380).

Anesthesia for screening colonoscopy is billed with code 00812; anesthesia for diagnostic or therapeutic colonoscopy is billed with code 00811.

When multiple endoscopies from the same endoscopic family are performed, payment will be bundled into the primary endoscopy procedure for providers re-contracted or newly contracted on or after June 1, 2021.

Screening colonoscopies can be performed on patients aged 45 to 75.

Coverage and payment depend on date of service, member eligibility/benefits, provider contract status, and correct coding; providers should confirm eligibility and benefits with Blue KC as needed.

Endoscopy and Related Procedure Codes

Endoscopic Procedures: ERCPCPT

43260-43273

Endoscopic Procedures: ERCP

Endoscopic Procedures: Esophagogastroduodenoscopy (EGD)CPT

43235-43210

Endoscopic Procedures: Esophagogastroduodenoscopy (EGD)

Flexible and Rigid Colonoscopy ProceduresCPT

45378-45398

Flexible and Rigid Colonoscopy Procedures

Flexible Sigmoidoscopy ProceduresCPT

45330-45350

Flexible Sigmoidoscopy Procedures

Endoscopy of Small Intestinal PouchCPT

44385-44386

Endoscopy of Small Intestinal Pouch

Anesthesia for diagnostic or therapeutic colonoscopyModifier

00811

Anesthesia for diagnostic or therapeutic colonoscopy

Anesthesia for screening colonoscopyModifier

00812

Anesthesia for screening colonoscopy

Provider Responsibilities and Eligibility Checks

Note

Confirm eligibility, benefits, and coverage limits

Confirm the member’s eligibility, benefits, and any applicable limits prior to providing services. For coverage confirmation or questions about whether services are eligible for coverage, contact the appropriate Blue KC provider hotline for the member’s line of business.

Commercial lines: Blue KC Provider Hotline 816-395-3929
Affordable Care Act: Provider Hotline 866-859-3822
Blue Medicare Advantage: Provider Hotline 866-508-7140

Definitions and Reporting Guidance

Screening colonoscopy — Definition and reporting guidance for screening colonoscopy.

DefinitionScreening colonoscopy: a test provided to a patient in the absence of signs or symptoms to test for presence of colorectal cancer or colorectal polyps.

Modifier guidanceIdentify screening or preventive colonoscopies with modifier 33 when the primary purpose is an evidence-based preventive service (USPSTF A or B) or other mandated preventive service.

Intent unchanged by findingsWhether a polyp or cancer is found does not change the screening intent of the procedure.

Age rangeScreening colonoscopies can be performed on patients aged 45 to 75.

Bundling with surgical endoscopyA diagnostic or screening endoscopy is included as part of a surgical endoscopic procedure and should not be separately reported (example: 45378 included in 45379–45398).

Endoscopic biopsy reporting — When biopsy is included in excision/removal codes and related reporting guidance.

Inclusion with excision/removalAn endoscopic biopsy performed at the same surgical site as an excision/removal (e.g., biopsy code 43202) is included in the excision/removal procedure and should not be reported separately (example: 43202 included as part of 43216).

Separate surgical site reportingWhen an endoscopic biopsy is performed on a separate surgical site unrelated to the excision/removal, the biopsy may be considered for separate payment if modifier 59 is reported and medical record documents distinct surgical sites.

Single technique multiple sitesIf a single endoscopic technique is performed on separate surgical sites, report the code only once (e.g., multiple esophageal polyps removed by snare — report code 43217 once).

Different techniques separate sitesIf different endoscopic techniques are performed on separate sites, multiple endoscopy codes may be reported (e.g., 43216 and 43217 when different techniques used).