Medicare and Endoscopy: Coverage and Cost

Endoscopy is one of those words that sounds like it belongs in a sci-fi movie (“Captain, the endoscope is approaching!”),
but it’s actually a very common medical procedure. Whether your doctor is looking for the cause of heartburn that won’t quit,
checking a suspicious bleed, or screening for colon cancer, the big question for most people isn’t only “Do I need this?”
It’s also: “Is Medicare going to cover it… and how much am I going to pay?”

Here’s the good news: Medicare often covers endoscopy when it’s medically necessary, and screening colonoscopy has special
preventive coverage rules. The not-so-fun news: the final cost can depend on why you’re getting the scope,
where you’re getting it, and how it’s billedplus whether anesthesia, biopsies, or lab work enter the chat.
Let’s break it down in plain English (with just enough humor to make medical billing slightly less terrifying).

What counts as “endoscopy,” anyway?

“Endoscopy” is a broad term for procedures that use a thin tube with a camera to look inside the body. In Medicare conversations,
people usually mean one of these:

• Upper endoscopy (EGD): Looks at the esophagus, stomach, and first part of the small intestine.
• Colonoscopy: Looks at the colon (large intestine) and rectum.
• Flexible sigmoidoscopy: Looks at the lower part of the colon.
• Enteroscopy: Looks deeper into the small intestine (less common).

These are typically outpatient procedures. You come in, get sedation (or anesthesia), take a nap of varying quality, and wake up
with a snack and a new appreciation for pants with elastic waistbands.

Medicare basics that control your endoscopy bill

Original Medicare: Part A vs. Part B (the short version)

Most endoscopies fall under Medicare Part B because they’re outpatient. Part B generally covers medically necessary
services used to diagnose or treat a condition (and also covers many preventive services).

If your endoscopy happens during an inpatient hospital admission, then Part A may cover much of the facility portion,
while professional services (like the physician’s work) are often billed under Part B. In 2026, the Part A inpatient hospital deductible is
$1,736, and Part B has an annual deductible of $283 (with a standard Part B monthly premium of $202.90).

The “80/20” rule (and why it’s famous)

For many Part B services, once you meet your Part B deductible, Medicare typically pays most of the Medicare-approved amount, and you pay the rest
often described as the classic “Medicare pays 80%, you pay 20%.” Where it gets tricky is that an endoscopy can create multiple charges:
the doctor’s fee, a facility fee, anesthesia, and pathology/lab services.

When Medicare covers endoscopy

Medicare Part B generally covers an endoscopy when it meets medical necessity standardsmeaning your clinician is using it to diagnose, evaluate, or treat a medical issue.
Common reasons include:

• Persistent GERD/heartburn, trouble swallowing, or unexplained chest discomfort
• GI bleeding, anemia, or black/tarry stools
• Ongoing abdominal pain, chronic nausea/vomiting
• Monitoring known conditions (like ulcers, Barrett’s esophagus, inflammatory bowel disease)
• Evaluating abnormal imaging or lab results

In these cases, expect the procedure to be treated as a diagnostic or therapeutic service under Part B, with typical cost sharing.

Screening vs. diagnostic: the billing plot twist

Screening colonoscopy (preventive) has special coverage

Medicare covers screening colonoscopies under Part B as a preventive service. Frequency depends on risk:
generally once every 24 months if you’re at high risk, or once every 120 months if you aren’t (with additional timing rules if you had a sigmoidoscopy).

If your provider accepts assignment, you pay nothing for the screening test itself in many cases.
But here’s the part that catches people off guard:

• If a polyp or other tissue is found and removed during the colonoscopy, you pay 15% of the Medicare-approved amount for the provider’s services.
  In a hospital outpatient setting or ambulatory surgical center, you also pay the facility 15% coinsurance.
  The Part B deductible doesn’t apply to the screening colonoscopy.

Translation: the appointment may start as “free,” then turn into “not free” the moment your doctor does exactly what you wanted them to doremove something suspicious.
Preventive medicine is a little bit like that friend who says, “Don’t worry, I’ve got this,” and then Venmos you later.

Follow-up colonoscopy after a positive test

Medicare also covers a follow-up colonoscopy after a positive Medicare-covered, non-invasive stool-based colorectal cancer screening test (and certain blood-based biomarker screening tests)
as a screening test.
That can matter for cost-sharingagain, with the important caveat that polyp/tissue removal changes what you owe.

Diagnostic colonoscopy and upper endoscopy (EGD)

If you’re getting a colonoscopy because you have symptoms (bleeding, anemia, pain, etc.) or you’re getting an upper endoscopy for evaluation and diagnosis,
Medicare typically treats that as outpatient medical care under Part B. In general, after you meet the Part B deductible, you pay a share of the Medicare-approved amount,
and additional facility charges may apply based on setting.

Where you get the endoscopy can change the cost

Ambulatory surgical center (ASC)

ASCs are outpatient facilities designed for same-day procedures. Under Part B, after you meet your Part B deductible, you typically pay 20%
of the Medicare-approved amount to the ASC and the doctor(s) treating you (other costs may apply).

Hospital outpatient department

Hospital outpatient settings can have a different cost structure. Medicare notes that you usually pay 20% of the Medicare-approved amount for the provider’s services,
and you’ll also usually pay the hospital a copayment for each service you get in a hospital outpatient setting (except certain preventive services).
In many cases, that hospital copayment can’t be more than the Part A inpatient hospital deductible for each service.

Practical takeaway: the same procedure may cost more in a hospital outpatient department than in a doctor’s office or ASCso it’s worth asking about the site of service,
especially if you’re trying to budget.

Inpatient hospitalization

If your endoscopy happens while you’re admitted as an inpatient, Part A cost-sharing rules may apply to the facility portion (including the Part A deductible),
and you might still see Part B charges for professional services. In 2026, the Part A inpatient hospital deductible is $1,736.

Why you might get multiple bills (and none of them say “thanks for your patience”)

Even when Medicare covers the endoscopy, you may see separate charges for:

• Professional fee: the gastroenterologist’s work
• Facility fee: the ASC or hospital outpatient department charge
• Anesthesia/sedation: sometimes billed separately
• Pathology: if tissue/polyps are removed and sent to a lab
• Additional services: biopsies, polypectomy, dilation, treatment of bleeding, etc.

This is normalannoying, but normal. Medicare coverage can still apply across these services, but your share depends on whether each part is preventive vs diagnostic,
whether deductibles apply, and what setting billed the service.

Medigap vs. Medicare Advantage: how your plan changes your out-of-pocket cost

Medigap (Medicare Supplement Insurance)

If you have Original Medicare, you can choose to add Medigap, which may help pay some of the costs Original Medicare doesn’t cover (like coinsurance).
This can be a big deal for procedures with multiple components (facility + physician + anesthesia + pathology).

Medicare Advantage (Part C)

Medicare Advantage plans must cover at least the same medically necessary services that Original Medicare covers, but the rules and cost-sharing can differ.
Plans may use networks, require referrals, and may require prior authorization for certain services.

One upside: Original Medicare has no yearly cap on out-of-pocket spending unless you have supplemental coverage, while Medicare Advantage plans have a yearly limit on what you pay
for covered servicesonce you hit it, you pay nothing for covered services for the rest of the year.

How to estimate (and often lower) your endoscopy costs

Want to avoid the “wait, why do I owe that?” moment? Use this checklist before the procedure:

1. Ask if it’s screening or diagnostic. If it’s colon cancer screening, confirm it will be billed as a screening colonoscopy.
2. Ask what happens if a polyp is removed. Under Medicare, polyp removal during a screening colonoscopy can trigger 15% cost-sharing.
3. Confirm the setting: doctor’s office, ASC, or hospital outpatient department. The site of service can affect facility charges.
4. Confirm assignment: do the clinicians accept Medicare assignment? This affects what you pay for preventive services.
5. Ask about anesthesia billing: will an anesthesiologist bill separately?
6. Ask about pathology: if biopsies are taken, will there be a separate lab/pathology charge?
7. Know your deductible status: if you haven’t met the Part B deductible ($283 in 2026), your out-of-pocket may be higher early in the year.
8. If you have Medicare Advantage, call the plan: ask about copays, prior authorization, and whether the facility and clinicians are in-network.

Cost examples (hypothetical, but realistic in structure)

Medicare-approved amounts vary widely by region, facility type, and what’s done during the procedure. These examples are simplified to show how the math usually works.

Example 1: Screening colonoscopy, no polyp removed

If your provider accepts assignment, many people pay $0 for the screening test itself.
(You could still have costs for non-covered extras, but the screening colonoscopy coverage is designed to be no-cost in that situation.)

Example 2: Screening colonoscopy, polyp removed in an ASC

Medicare rules note you may pay 15% for the provider’s services and 15% facility coinsurance in an ASC or hospital outpatient setting,
with no Part B deductible applying for the screening colonoscopy.

Hypothetical math: If the Medicare-approved amount is $1,200 for the physician portion and $2,000 for the facility portion, 15% would be $180 + $300 = $480.

Example 3: Diagnostic upper endoscopy (EGD) at an ASC after you’ve met your Part B deductible

In an ASC, after the Part B deductible, you generally pay 20% of the Medicare-approved amount to both the facility and the physician.

Hypothetical math: Physician $700 + facility $1,100 = $1,800 total Medicare-approved.
20% coinsurance = $360 (plus any separate anesthesia/pathology coinsurance if billed).

Example 4: Diagnostic endoscopy in a hospital outpatient department

Medicare notes you usually pay 20% of the Medicare-approved amount for the clinician’s services, and you’ll also usually pay the hospital a copayment per service,
with limits in many cases tied to the Part A inpatient deductible amount for each service.

Translation: the hospital outpatient bill can look different than an ASC billeven when the scope is the same.

Frequently asked questions

Does Medicare cover colonoscopy and upper endoscopy on the same day?

Medicare can cover medically necessary services under Part B, and clinicians sometimes perform an upper endoscopy and colonoscopy during the same visit
when it’s clinically appropriate. Your cost will depend on whether any part is preventive vs diagnostic, and whether additional services (like biopsy/polyp removal) occur.

Why is my “preventive” colonoscopy not totally free?

Under Medicare’s screening colonoscopy rules, if a polyp or tissue is removed, you may owe 15% for the provider and 15% for the facility (ASC/hospital outpatient),
even though the original intent was preventive.

Will Medicare pay if my doctor says it’s “medically necessary”?

Medical necessity is a key standard for Part B coverage of diagnostic services, but coverage still depends on proper documentation and billing.
Your best move is to ask the clinician’s office what diagnosis code and procedure code family they expect to use and whether Medicare coverage is typical for your indication.

Real-world experiences (the “what it feels like” section about )

If you ask a group of Medicare beneficiaries about endoscopy costs, you’ll hear a theme: the procedure itself is usually straightforward, but the billing can feel like a scavenger hunt.
Not a fun scavenger hunt, eithermore like the kind where the prize is “a slightly smaller bill than you feared.”

One common story goes like this: someone schedules a screening colonoscopy, hears “preventive,” and mentally files it under “free, like the samples at Costco.”
Then a polyp is found and removedexactly the point of screeningand a bill arrives later. The surprise isn’t that Medicare covered the care; it’s that “covered” doesn’t always mean
“no cost.” Medicare’s screening colonoscopy rules spell out that polyp or tissue removal can trigger 15% cost-sharing for the provider and, in certain settings, for the facility too.
People often say they wish someone had told them upfront: “You might owe money if we actually do the thing we’re here to do.”

Another experience is the “location switcheroo.” A patient assumes all outpatient centers are basically the same, only to learn that a hospital outpatient department can have different
copayment structures than an ambulatory surgical center. Sometimes the scheduling department picks a location that’s convenient or available sooner, not realizing the patient is trying
to keep costs down. The folks who feel best about their final bill tend to be the ones who asked early: “Is this at an ASC or hospital outpatient?” and “Can you estimate my facility fee?”
Medicare itself notes you may pay more for outpatient services in a hospital setting than for the same care in a doctor’s office, and that hospital outpatient copayments work differently.

People with Medigap often describe endoscopy day as “boring,” and in health insurance, boring is a compliment. When multiple bills come indoctor, facility, anesthesia, pathologyMedigap
may reduce the sting of coinsurance depending on the policy. In contrast, Medicare Advantage members sometimes describe the experience as very plan-dependent: one person has a simple copay,
another person has to confirm network status, get prior authorization, or navigate where the plan prefers the procedure be done. Some say they’ve learned to call their plan first and ask,
“What will I pay if I do this at Location A versus Location B?”because the difference can be dramatic. Medicare notes that Advantage plans have different rules (like prior authorization),
and that Original Medicare and Medicare Advantage handle out-of-pocket costs differently, including the existence of a yearly out-of-pocket limit in many Advantage plans.

The most useful “experienced patient” advice is surprisingly simple: treat endoscopy planning like booking a flight. You don’t just ask, “Is there a seat?”
You ask, “What’s the total price, what’s included, and what happens if anything changes?” If a biopsy is taken, will pathology bill separately? If an anesthesiologist is involved, is that
a separate claim? Is your deductible already met this year? Once patients start asking those questions, they usually feel more in controland their wallets tend to feel less ambushed.

Conclusion

Medicare coverage for endoscopy is usually strong when the procedure is medically necessary, but the cost depends on the “why” (screening vs diagnostic), the “where” (ASC vs hospital outpatient),
and the “what else” (polyp removal, biopsies, anesthesia, pathology). Screening colonoscopy can be $0 in many casesuntil a polyp is removed, which can trigger 15% cost-sharing in certain settings.
The best strategy is to ask smart questions ahead of time, confirm assignment and location, and understand how your coverage type (Original Medicare, Medigap, or Medicare Advantage) affects cost-sharing.
A little planning up front can turn a confusing bill into a predictable oneand that’s a win worth celebrating (even if you’re celebrating in a paper gown).