An endoscopy is a medical procedure using a flexible tube (endoscope) equipped with a light and camera to visualize the inside of a body cavity or organ. Physicians use this technique to examine areas like the digestive tract or lungs to diagnose or treat conditions such as internal bleeding or inflammation. Medicare generally covers endoscopies, but coverage and out-of-pocket costs vary. The primary factor determining coverage is whether the procedure is performed for routine preventive screening or for diagnostic and therapeutic purposes based on existing symptoms.
Screening and Diagnostic Endoscopies Under Part B
Medicare Part B, which covers outpatient medical services, is the primary source of coverage for most endoscopies. This includes physician services and procedures performed in ambulatory surgical centers or outpatient hospital settings. Coverage is determined by medical necessity and purpose, categorized as either screening or diagnostic.
For colorectal cancer screenings like colonoscopies, coverage frequency depends on risk. Individuals at average risk are covered once every ten years. Those considered high-risk, perhaps due to a history of inflammatory bowel disease or adenomatous polyps, are eligible for a screening colonoscopy every two years.
If a patient presents with symptoms such as unexplained abdominal pain, blood in the stool, or difficulty swallowing, the procedure is considered diagnostic. Furthermore, if a screening colonoscopy begins as preventive but the physician removes a polyp or takes a tissue sample, the billing status changes to diagnostic or therapeutic. This change in designation significantly impacts the patient’s financial responsibility, even though the physical procedure remains the same.
Patient Financial Responsibility and Costs
Out-of-pocket costs under Original Medicare depend heavily on whether the procedure is classified as screening or diagnostic. For screening colonoscopies, Medicare covers the full cost, provided the provider accepts Medicare assignment. This zero-cost coverage applies to the procedure itself, including professional and facility fees, regardless of whether the Part B annual deductible has been met.
If a screening procedure transitions to diagnostic, such as when a polyp is removed, the cost structure changes. For procedures performed through 2026, the patient’s coinsurance for physician and facility fees is 15% of the Medicare-approved amount, a reduced rate from the standard 20%. The Part B deductible still does not apply in this scenario, recognizing the procedure’s initial preventive nature.
For endoscopies that are diagnostic from the start, such as an upper endoscopy to investigate stomach pain, standard Part B cost-sharing rules apply. The patient must first meet the annual Part B deductible (\$257 in 2025). After the deductible is met, the patient is responsible for 20% of the Medicare-approved amount, and Medicare covers the remaining 80%. The final cost is also influenced by the setting, as procedures in an ambulatory surgical center are often less expensive than those performed in a hospital outpatient department.
Alternative Coverage Options and Settings
While most endoscopies fall under Part B, coverage shifts to Medicare Part A if the procedure requires an inpatient hospital stay. This is rare but may occur due to patient complexity or post-procedure complications. In this situation, the patient is responsible for the Part A deductible per benefit period (\$1,676 in 2025). Once the deductible is met, Part A typically covers the full cost of the medically necessary endoscopy as part of the hospital stay.
Individuals enrolled in a Medicare Advantage (Part C) plan receive benefits through a private insurer contracted with Medicare. These plans must provide at least the same coverage as Original Medicare, including endoscopies and zero-cost preventive screenings. However, Part C plans structure financial responsibility differently, often using flat-rate copayments instead of Part B’s percentage-based coinsurance. Part C plans may also impose requirements like prior authorization for non-emergency procedures or limit coverage to a specific provider network.
For beneficiaries with a Medigap policy, that private plan can help cover the out-of-pocket costs associated with Original Medicare. Medigap plans can cover the Part B coinsurance, deductibles, or both, reducing the financial burden of a diagnostic endoscopy.