What Medicare Pays vs. What You Might Be Charged

Category	Amount
Medicare Allowed Rate What Medicare approves for this service	$302.28
Typical Billed Amount What providers commonly charge	$600 – $4000
Potential Markup How much more you might pay vs. Medicare rate	1223% above Medicare

Why the difference? Providers set their own prices. Without insurance, you may be billed the full amount. Even with insurance, your co-pay is often based on the provider's charge — not the Medicare rate.

What CPT Code 45380 Means

CPT code 45380 represents a colonoscopy with biopsy, which means your doctor used a flexible tube with a camera to examine your colon and took small tissue samples for testing. This is different from a regular screening colonoscopy because tissue was actually removed and sent to a lab.

Your doctor uses this code when they find something suspicious during your colonoscopy - like a polyp, unusual tissue, or an area that needs further examination. The biopsy helps determine if the tissue is normal, precancerous, or cancerous. Even if the biopsy results come back normal, this code is still correct because the tissue removal and testing occurred.

This procedure is commonly performed to investigate symptoms like unexplained bleeding, changes in bowel habits, or to follow up on abnormal imaging results. It's also used when polyps are found during a routine screening and need to be tested.

What to Expect on Your Bill

When you see CPT code 45380 on your medical bill, you can expect charges to vary significantly depending on where you had the procedure done. The Medicare reimbursement rate for this code is $302.28, but typical charges range from $600 to $4000. Hospital outpatient departments usually charge more than ambulatory surgery centers or doctor's offices.

Your bill may include separate charges for the facility fee (where the procedure was performed), the physician fee (your doctor's professional services), anesthesia, and pathology services for examining the biopsy tissue. These are typically billed separately and are normal parts of the process.

It's important to know that CPT 45380 has a high error rate, meaning it's frequently billed incorrectly. Common mistakes include using this code when no biopsy was actually taken, or confusing it with similar codes like 45378 (colonoscopy without biopsy) or 45385 (colonoscopy with polyp removal).

How to Verify Your Billing is Correct

To check if you were billed correctly, first confirm that tissue was actually removed during your colonoscopy. Review your procedure notes or discharge summary - it should clearly mention that biopsies were taken. If you only had a screening colonoscopy with no tissue removed, you should see code 45378 instead, not 45380.

Compare your charges to the typical range of $600-$4000, keeping in mind that hospital settings usually cost more than outpatient centers. If your charge seems unusually high, contact your provider's billing department to request an itemized bill and explanation of charges.

If you believe you were billed incorrectly, gather your procedure documentation and contact the billing department immediately. Common errors include billing for a biopsy when none was performed, or double-billing for related services. Don't hesitate to ask for a review of your charges - billing errors are common with this code, and providers are usually willing to investigate and correct mistakes.

Billing alert: CPT 45380 has a high error rate. This code is frequently confused with 45378 and 45385. If you see this code on your bill, it's worth double-checking that the service matches what actually happened during your visit.

Codes Often Confused With CPT 45380

CPT 45378 CPT 45385

Frequently Asked Questions

Why is my colonoscopy billed as 45380 instead of a regular screening?

Code 45380 is used because your doctor took tissue samples (biopsies) during the procedure. Even if you came in for routine screening, once tissue is removed for testing, the billing code changes from a simple screening to a colonoscopy with biopsy.

How much should I expect to pay for CPT code 45380?

Charges typically range from $600 to $4000, with Medicare paying $302.28. Your actual cost depends on your insurance coverage, where the procedure was performed, and your deductible. Hospital outpatient departments usually charge more than surgery centers.

What if I was charged for 45380 but no biopsy was taken?

This would be a billing error since 45380 specifically requires tissue removal. Contact your provider's billing department immediately with your procedure documentation. You should likely be billed under code 45378 for a standard colonoscopy instead.