CPT code 74263 – Screening CT colonography

Key takeaways

CPT code 74263 reports screening CT colonography for an asymptomatic patient. Any symptom or positive stool test moves the claim to 74261 or 74262.

Medicare has covered screening CT colonography under 74263 since January 1, 2025, with no deductible or coinsurance, for patients aged 45 and older.

Medicare edits every 74263 claim for age and frequency. An average-risk patient qualifies once every 59 months after their last screening CT colonography.

HCPCS G0106, G0120 and G0122 were deleted on January 1, 2025, along with barium enema screening, so none of them applies to CT colonography.

Pabau’s claims management software sends claims through Claim.MD, runs eligibility checks, and warns when a case is missing its prior authorization code.

What is CPT code 74263?

CPT code 74263 is defined by the American Medical Association (AMA) as Computed tomographic colonography, screening, including image postprocessing.

The scan produces detailed cross-sectional images of the entire colon and rectum without an endoscope. The descriptor limits 74263 to screening. The patient must be asymptomatic and presenting for routine colorectal cancer screening, not a diagnostic workup.

Bowel preparation is required before the scan. Standard protocols use a cathartic prep to cleanse the colon, though some facilities use reduced-prep or fecal-tagging protocols.

The radiologist acquires thin-slice CT images in supine and prone positions, then performs 2D multiplanar reconstructions and 3D endoluminal rendering before issuing a structured report. All of this work is bundled into CPT code 74263 as a global service.

CPT 74263 vs 74261 vs 74262: Choosing the right code

The 74261-74263 family uses the same technology but splits by clinical indication and contrast use. Picking the wrong code turns a clean claim into a denial or, worse, an upcoding audit finding.

The clinical trigger decides the code. A patient with rectal bleeding, a change in bowel habits, or a positive FIT test is symptomatic, however the order is worded. Bill 74261 or 74262 for those encounters. A personal or family history of polyps or colorectal cancer does not make the patient symptomatic. Medicare treats it as high risk instead, which changes the screening interval.

Code selection is the first checkpoint in the medical billing process. An error here carries through charge entry and claim submission, so settle the indication before the order is coded.

Medicare and insurance coverage for CPT 74263

Medicare added screening CT colonography as a covered colorectal cancer screening test in the CY 2025 Physician Fee Schedule final rule. Coverage applies to services on or after January 1, 2025. The patient pays no deductible and no coinsurance for the screening study.

The same rule ended Medicare coverage of screening barium enema, and HCPCS G0106, G0120 and G0122 were deleted from January 1, 2025. G0120 described a barium enema as an alternative to G0105, the high-risk screening colonoscopy code. It never described CT colonography, and no G code replaces 74263 on a Medicare claim.

CMS change request 13248 sets the conditions a Medicare 74263 claim must meet:

• Age: the patient is 45 or older on the date of service.
• Clinical picture: the patient is asymptomatic. There are no signs of colorectal disease, such as lower GI pain, blood in the stool, or a positive stool test.
• Order: the treating physician orders the study.
• Average-risk frequency: at least 59 months have passed since the month of the last screening CT colonography. At least 47 months must also have passed since the last flexible sigmoidoscopy or screening colonoscopy.
• High-risk frequency: at least 23 months have passed since the last screening CT colonography or screening colonoscopy. The claim must carry a high-risk diagnosis from List 1 of the NCD 210.3 coding spreadsheet.
• Institutional claims: hospitals bill 74263 on type of bill 12X, 13X or 85X. Claims on any other type of bill are returned to the provider.

CMS lists average risk as a coverage criterion, yet the same instructions set an interval for high-risk patients. Ask your Medicare Administrative Contractor (MAC) how it applies the high-risk rule before you book a high-risk patient for screening CT colonography.

Read in order, those conditions come down to three checks a scheduler can run before the patient is booked.

Other payers set their own terms:

• Traditional Medicare: covered within the limits above. Issue an Advance Beneficiary Notice (ABN) only when the patient falls outside the age or frequency limit and still wants the study.
• Medicare Advantage: plans must cover the same screening benefit as Traditional Medicare. Network rules and prior authorization vary, so verify with the plan before scheduling.
• Commercial insurers: the 2021 United States Preventive Services Task Force (USPSTF) recommendation lists CT colonography every five years for adults aged 45 to 75. Most plans cover recommended screening, but confirm age limits and prior authorization before billing.
• Medicaid: state-dependent. Some state Medicaid programs cover screening CT colonography and others do not, so check your state’s fee schedule.

Reimbursement rates for CPT code 74263

Because Medicare now covers screening CT colonography, the Medicare Physician Fee Schedule (MPFS) amount for 74263 is what Medicare pays for the study. The 2026 fee schedule gives the global service 2.22 work RVUs and 25.00 total RVUs.

At the 2026 conversion factor of $33.4009, that comes to about $835 nationally before geographic adjustment. Use the CMS Physician Fee Schedule lookup for locality-specific amounts.

A freestanding imaging center will not collect those technical amounts. CT colonography is an imaging service, so Medicare caps the non-facility technical payment at the hospital outpatient (OPPS) rate.

In the October 2026 CMS relative value file (RVU26D), the capped global amount runs from about $322 to $498 by locality. The capped technical component runs from about $209 to $351.

In a hospital outpatient department, the hospital bills the technical side under OPPS and the radiologist bills modifier 26. Clinicians in a qualifying alternative payment model use a slightly higher 2026 conversion factor of $33.5675.

When the radiologist works in a hospital or imaging center that owns the equipment, the two entities split the global code. They use modifiers 26 and TC. A freestanding radiology group that employs its own radiologists and owns its scanners bills the global rate without a modifier.

Billing 74263 without a modifier when two entities share the service creates duplicate billing, which payers audit closely.

Modifiers for CPT 74263

Modifier selection for CPT 74263 follows standard radiology modifier rules. The table below summarizes the five modifiers most often seen on 74263 claims.

Never append modifiers 26 and TC to the same claim line. Each one represents one side of the global split, and payers reject a line that carries both.

Diagnosis codes to pair with CPT code 74263

Pairing CPT code 74263 with the correct ICD-10-CM code establishes screening intent and heads off a medical-necessity denial. For an average-risk patient, the first-listed code is Z12.11. Medicare also checks high-risk claims against List 1 of the NCD 210.3 coding spreadsheet, so confirm a high-risk code is on the current list.

Avoid symptom codes (rectal bleeding, change in bowel habits, abdominal pain) as the primary diagnosis pointer on a 74263 claim. Those codes signal a diagnostic workup, not screening. The payer will deny 74263 and point you to 74261 or 74262.

Documentation requirements for billing CPT 74263

A compliant 74263 claim depends on a radiology report that documents each part of the global service. Payers and auditors expect the record to include the elements below, and each one also supports your wider medical billing compliance program.

• Ordering physician and clinical indication: the order must state colorectal cancer screening. Diagnostic language on the order invalidates the screening code.
• Screening history: record the dates of the last screening CT colonography, colonoscopy, or flexible sigmoidoscopy. Medicare’s frequency edit turns on those dates.
• Bowel preparation type and adequacy: document the prep protocol and whether cleansing was adequate for interpretation. Poor prep with a negative study may warrant a recommendation to repeat with full prep.
• Imaging technique: record scan parameters, supine and prone acquisitions, slice thickness, and radiation dose (CTDI and DLP).
• 2D and 3D reconstructions: multiplanar 2D review and 3D endoluminal rendering are both bundled into 74263. The report must confirm both were performed.
• Structured interpretation: the report should follow the CT Colonography Reporting and Data System (C-RADS) or an equivalent format. Each segment of the colon must be evaluated.
• Radiologist attestation: the interpreting physician must sign and date the final report. An electronic signature with a date and time stamp meets this requirement.

Common denial reasons for CPT 74263 claims and how to avoid them

Most 74263 denials fall into six patterns. Recognizing the pattern on the remittance advice tells the biller what to fix. Effective denial management in healthcare starts with identifying which pattern caused each rejection before working the account.

• Medicare screening edits (CARC 119, 6 or 167): A screening interval that is too short brings CARC 119 with RARC N640. A patient under 45 brings CARC 6 with RARC N129. A high-risk claim without a List 1 diagnosis gets CARC 167 with RARC MA63. Prevention: check age and screening history before booking, and use an ABN with modifier GA when the patient falls outside the limits.
• Wrong code for indication (CO-50): a symptomatic patient billed under 74263 instead of 74261 or 74262. Prevention: audit the physician order for clinical language before coding.
• Missing prior authorization (CO-15): commercial plans and radiology benefit managers such as National Imaging Associates (NIA) often require prior authorization for CT colonography. Prevention: build a prior authorization worklist into scheduling and confirm the number before the date of service.
• Incorrect ICD-10 pairing (CO-11): symptom codes or unrelated diagnoses paired with 74263. Prevention: use Z12.11 as the primary first-listed code and check the diagnosis pointer on the claim form.
• Global bill vs split bill mismatch: the radiologist appends modifier 26, but the facility also bills the global code without TC. Prevention: confirm the billing arrangement at credentialing and record it in the billing system.
• Bundling with same-day optical colonoscopy: NCCI edits may bundle 74263 with CPT 45378 on the same date of service. Prevention: review the edits before submitting both codes, and use modifier 59 only when documentation supports a distinct procedure.

For practices working a denial backlog, our denial code reference explains the CARC and RARC codes on the ERA. Billers can then read the exact reason code and respond correctly.

Same-day billing: CPT 74263 and CPT 45378

CPT 45378 is a diagnostic flexible colonoscopy, including specimen collection by brushing or washing when performed. Billing it with CPT 74263 on the same date is generally not reimbursable. The two procedures are alternative ways to evaluate the colon. Payers treat a same-day pair as duplicating one purpose.

NCCI edits may bundle these codes, depending on the edit table in effect on the date of service. When an edit pairs 74263 and 45378, the column 2 code is denied unless modifier 59 appears. The documentation must also support a distinct clinical scenario.

Modifier 59 might hold in one rare case. An optical colonoscopy is incomplete because of poor prep or an obstruction, and CT colonography follows the same day. Even here, payer policy governs, so confirm coverage first and document the clinical rationale.

When running insurance eligibility verification before same-day procedures, check CT colonography coverage as its own line item.

Quality reporting: CPT 74263 and Quality ID 113

CT colonography counts as colorectal cancer screening under Quality ID 113 (Colorectal Cancer Screening), which covers patients aged 45 to 75. A CT colonography in the measurement period or the four years before it meets the measure.

The record has to show that the clinician reviewed the screening report. Check the current year’s Quality Payment Program specification for denominator exclusions and for the reporting options that carry the measure. Both change annually.

How claims management software prevents 74263 denials

Most 74263 denials are settled before the scan. The patient’s age, screening history, payer, and authorization status decide whether the claim pays. When those details sit in separate systems, the biller learns about a problem from the remittance advice.

In Pabau, the practice software we build, the patient record, payer details, and claims sit in one system. Its claims management software sends CMS-1500 and 837P claims through the Claim.MD clearinghouse and runs eligibility checks before the appointment. ERA remittances and secondary claims are handled against the same patient.

Prior authorization codes, dates, and sessions are tracked on the patient’s case, and Pabau warns when one is missing. For a commercial 74263 study, a missing authorization surfaces at scheduling, not as a CO-15 denial weeks later.

Catch 74263 claim problems before the scan

Pabau’s claims management software sends claims through Claim.MD, checks patient eligibility, and warns when a case is missing its prior authorization. See how it works for radiology and imaging practices.

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Conclusion

The 2025 coverage change turned screening CT colonography from a cash-pay study into a Medicare benefit. A practice that still collects an ABN on every Medicare screening CT colonography should stop. A patient who meets the age and frequency limits owes nothing for the study, and an ABN has no basis there.

The risk has moved to the frequency edit. A study booked 40 months after a screening colonoscopy will deny, so the screening history belongs on the order before the patient is scheduled.

Get the indication, the history, and the diagnosis code right, and 74263 pays like any other covered screening. Book a demo to see how Pabau keeps eligibility, authorization, and claims in one workflow for imaging practices.

Continue your research

Need a clean-claim checklist for radiology billing? Submitting a clean claim walks through the fields payers audit first and how to get them right before transmission.

Working a denial backlog? Revenue cycle management fundamentals covers the end-to-end workflow from charge capture through payment posting.

Need to understand how the clearinghouse fits in? How Claim.MD works as a clearinghouse explains the 837P transmission path and how ERA remittances come back.

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