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Does Medicare Cover Endoscopy?

February 24, 2022

Does Medicare Cover Endoscopy?

There are a variety of medical procedures which we know we should go through, but often don’t want to. They can be very uncomfortable, but in the end, we get an important diagnosis or better informed about our health.

Endoscopy is one of those types of procedures. These are used to look at things like your ears, nose, throat, colon, or joints to see if there are concerns that need to be addressed. You may be asking yourself, “Is an endoscopy covered under Medicare?”

In most cases, endoscopy is an outpatient procedure, so it is covered under Medicare if it’s medically necessary. Let’s take a look at this procedure and how it’s covered by Medicare.

What Is an Endoscopy?

An endoscopy is often referred to as a “scope,” is a general term that refers to looking at the inside of your body using a small camera. “Endo-” is a prefix that means “inner.”

There are a variety of types of endoscopy, each with its own name and focus. For example, an arthroscopy is a type of endoscopy that focuses on joints (arthro- is a prefix referring to joints). So your doctor might recommend you have an arthroscopy of your knee. On the other hand, laparoscopic procedures look at your abdomen for issues like gallbladder problems or hernias.

The good news is that these procedures are minimally invasive, meaning that you can avoid major incisions and long surgery recovery time by having an endoscopic procedure instead of open surgery.

Because they are minimally invasive, endoscopies are often performed as an outpatient procedure where you go home the same day, rather than staying in the hospital. As long as they are medically necessary and performed by someone who participates in Medicare and accepts assignments, they are covered.

How Much Does an Endoscopy Cost With Medicare?

The average cost of an endoscopy to someone on Medicare is between $57 and $112 for CPT 50572, depending on the type of facility used.

If you have Original Medicare, outpatient procedures are generally covered under Medicare Part B. That means that you pay 20% of the Medicare-approved costs, along with your deductible if applicable, and Medicare pays the rest.

Under a Medicare Advantage plan, the cost could be different. Many Advantage plans have a defined copayment for an outpatient procedure instead of dividing it by percentage. This can make the cost more predictable and it may be lower than you’d pay with Original Medicare. You’ll want to contact your insurance provider to find out the details.

Keep in mind that your endoscopy may require approval from Medicare or the Medicare Advantage plan before you move forward. Your doctor can request that approval for you. Also, your provider will need to be within the network of your insurance plan.

How Does Medicare Pay for Endoscopy?

Original Medicare pays for an endoscopy based on the billing code that the provider sends to the insurer. There is a Medicare-approved amount for each procedure. If your deductible hasn’t yet been paid, Medicare deducts that amount from the fee. Then, Medicare pays 80% of the remainder.

You receive a bill for any remaining deductible you haven’t paid, along with your 20% of the procedure cost.

With Medicare Advantage, you’re more likely to pay a flat fee as a copayment, rather than waiting for a bill to see how much your percentage coinsurance amounts to. This can help bring peace of mind by being easier to budget for and possibly lower than the amount you’d pay with Original Medicare.

You’ll need to look at the specifics of your plan so you know what to expect. Don’t be afraid to contact your insurer to get more information about how a specific endoscopy will be covered.

Learn More About Medicare and Endoscopy

This guide answered many of the common questions about Medicare coverage of endoscopies, but you might have specific questions about your own situation. Or, perhaps you want to talk to a licensed agent to compare Medicare plans and ensure you have what’s best for your needs.

Either way, feel free to contact us! We’re here to help.

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