Colonoscopy and Sigmoidoscopy-Diagnostic (L30304)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30304 LCD Title Colonoscopy and Sigmoidoscopy-Diagnostic Contractor's Determination Number GI-006 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 09/15/2009 Original Determination Ending Date Revision Effective Date For services performed on or after 03/01/2012 Revision Ending Date |
CMS National Coverage Policy
Title XVIII of the Social Security Act (SSA or the Act), Section 1862(a) (1) (A), explains that payment may be allowed only for those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the SSA, Section 1833(e), prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Title XVIII of the SSA, Section 1862(a)(7), states that Medicare will not cover any services or procedures associated with routine physical checkups.
42 Code of Federal Regulations, 410.32, Diagnostic X-Rays, diagnostic laboratory tests, and other diagnostic tests: Conditions. This section describes regulations that apply to performing these tests.
Pub 100-02, Benefit Policy Manual, Chapter 15, Section 80, describes the requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
Pub 100-02 Benefit Manual, Chapter 15- Covered Medical and Other Health Services, Section 280.2 -Colorectal Cancer Screening
Pub.100-04 Medicare Claims Processing Manual -Chapter 18 Preventive and Screening Services, Section 60 - Colorectal Cancer Screening
Title XVIII of the SSA, Section 1833(e), prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Title XVIII of the SSA, Section 1862(a)(7), states that Medicare will not cover any services or procedures associated with routine physical checkups.
42 Code of Federal Regulations, 410.32, Diagnostic X-Rays, diagnostic laboratory tests, and other diagnostic tests: Conditions. This section describes regulations that apply to performing these tests.
Pub 100-02, Benefit Policy Manual, Chapter 15, Section 80, describes the requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
Pub 100-02 Benefit Manual, Chapter 15- Covered Medical and Other Health Services, Section 280.2 -Colorectal Cancer Screening
Pub.100-04 Medicare Claims Processing Manual -Chapter 18 Preventive and Screening Services, Section 60 - Colorectal Cancer Screening
Indications and Limitations of Coverage and/or Medical Necessity
This LCD only applies to diagnostic colonoscopies. Refer to the Medicare Internet Only Manuals (IOM) for coverage of colorectal cancer screening procedures.
Sigmoidoscopy and colonoscopy testing allows for the direct visualization of the lower gastrointestinal tract. Inspection is performed with an illuminated tube. These procedures are performed to detect polyps, tumors and other lesions of the intestines. The site of pathology can be identified during a colonoscopy and a biopsy can be obtained.
Definitions:
1. Sigmoidoscopy (CPT 45330-45335, 45337-45342, 45345) is the examination of the entire rectum and sigmoid colon, and includes examination of a portion of the descending colon.
2. Colonoscopy (CPT 44388-44397, 45355, 45378-45387, 45391, 45392) is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum.
Indications and Limitations of Coverage and/or Medical Necessity
A. The following are Medicare-covered indications for Diagnostic Colonoscopy:
1. Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as filling a defect or stricture
2. Evaluation of unexplained gastrointestinal bleeding:
a. Hematochezia not thought to be from rectum or perianal source,
b. Melena of unknown origin; after an upper GI source has been excluded,
c. Presence of fecal occult blood.
3. Unexplained iron deficiency anemia.
4. Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp.
5. Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management.
6. Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., with weight loss).
7. Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source).
8. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasm, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).
9. Removal of foreign body.
10. Excision of colonic polyps.
11. Decompression of acute nontoxic megacolon or sigmoid volvulus, pseudo obstruction of the colon (Ogilvie's syndrome).
12. Balloon dilatation of stenotic lesions (e.g., anastomotic strictures).
13. Palliative treatment of stenosing or bleeding neoplasm.
14. Marking a neoplasm for localization.
15. Evaluation of a patient with endocarditis due to streptococcus bovis or any bacterium of enteric origin;
16. Suspected disease of terminal ileum
17. Evaluation of acute colonic ischemia/ischemic bowel disease
18 In patients with Crohn's colitis and chronic ulcerative colitis: colonoscopy every one or two years with multiple biopsies for detection of cancer and dysplasia in patients with:
a. Pancolitis of eight or more years duration; or
b. Left-sided colitis of 15 or more years duration
19. Evaluation within 6 months of the removal of sessile polyps to determine and document total excision. If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 months. After evidence of total excision without return of the polyp, repeat colonoscopy yearly
20. Patients undergoing curative resection for colon or rectal cancer should undergo a colonoscopy 1 year after the resection (or 1 year following the performance of the colonoscopy that was performed to clear the colon of synchronous disease).
B. A diagnostic colonoscopy is not considered medically necessary for the following conditions:
1. Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy.
2. Acute limited diarrhea.
3. Hemorrhoids.
4. Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management.
5. Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn's colitis, chronic ulcerative colitis).
6. Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease.
7. Upper GI bleeding or melena with a demonstrated upper GI source.
C. A diagnostic flexible sigmoidoscopy is covered for the following indications:
1. Evaluation of suspected distal colonic disease when there is no indication for a colonoscopy.
2. Evaluation for anastomotic recurrence in rectosigmoid carcinoma.
3. All of the covered indications listed for a diagnostic colonoscopy.
D. A diagnostic flexible sigmoidoscopy is not indicated when a colonoscopy is indicated.
Sigmoidoscopy and colonoscopy testing allows for the direct visualization of the lower gastrointestinal tract. Inspection is performed with an illuminated tube. These procedures are performed to detect polyps, tumors and other lesions of the intestines. The site of pathology can be identified during a colonoscopy and a biopsy can be obtained.
Definitions:
1. Sigmoidoscopy (CPT 45330-45335, 45337-45342, 45345) is the examination of the entire rectum and sigmoid colon, and includes examination of a portion of the descending colon.
2. Colonoscopy (CPT 44388-44397, 45355, 45378-45387, 45391, 45392) is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum.
Indications and Limitations of Coverage and/or Medical Necessity
A. The following are Medicare-covered indications for Diagnostic Colonoscopy:
1. Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as filling a defect or stricture
2. Evaluation of unexplained gastrointestinal bleeding:
a. Hematochezia not thought to be from rectum or perianal source,
b. Melena of unknown origin; after an upper GI source has been excluded,
c. Presence of fecal occult blood.
3. Unexplained iron deficiency anemia.
4. Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp.
5. Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management.
6. Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., with weight loss).
7. Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source).
8. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasm, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).
9. Removal of foreign body.
10. Excision of colonic polyps.
11. Decompression of acute nontoxic megacolon or sigmoid volvulus, pseudo obstruction of the colon (Ogilvie's syndrome).
12. Balloon dilatation of stenotic lesions (e.g., anastomotic strictures).
13. Palliative treatment of stenosing or bleeding neoplasm.
14. Marking a neoplasm for localization.
15. Evaluation of a patient with endocarditis due to streptococcus bovis or any bacterium of enteric origin;
16. Suspected disease of terminal ileum
17. Evaluation of acute colonic ischemia/ischemic bowel disease
18 In patients with Crohn's colitis and chronic ulcerative colitis: colonoscopy every one or two years with multiple biopsies for detection of cancer and dysplasia in patients with:
a. Pancolitis of eight or more years duration; or
b. Left-sided colitis of 15 or more years duration
19. Evaluation within 6 months of the removal of sessile polyps to determine and document total excision. If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 months. After evidence of total excision without return of the polyp, repeat colonoscopy yearly
20. Patients undergoing curative resection for colon or rectal cancer should undergo a colonoscopy 1 year after the resection (or 1 year following the performance of the colonoscopy that was performed to clear the colon of synchronous disease).
B. A diagnostic colonoscopy is not considered medically necessary for the following conditions:
1. Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy.
2. Acute limited diarrhea.
3. Hemorrhoids.
4. Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management.
5. Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn's colitis, chronic ulcerative colitis).
6. Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease.
7. Upper GI bleeding or melena with a demonstrated upper GI source.
C. A diagnostic flexible sigmoidoscopy is covered for the following indications:
1. Evaluation of suspected distal colonic disease when there is no indication for a colonoscopy.
2. Evaluation for anastomotic recurrence in rectosigmoid carcinoma.
3. All of the covered indications listed for a diagnostic colonoscopy.
D. A diagnostic flexible sigmoidoscopy is not indicated when a colonoscopy is indicated.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 013x | Hospital Outpatient |
| 014x | Hospital - Laboratory Services Provided to Non-patients |
| 071x | Clinic - Rural Health |
| 085x | Critical Access Hospital |
Revenue Codes:
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
| 320X | Radiology - Diagnostic - General Classification |
| 360X | Operating Room Services - General Classification |
| 0450 | Emergency Room - General Classification |
| 490X | Ambulatory Surgical Care - General Classification |
| 510X | Clinic - General Classification |
| 520X | Free-Standing Clinic - General Classification |
| 0750 | Gastro-Intestinal (GI) Services - General Classification |
| 760X | Specialty Services - General Classification |
| 44388 | COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) |
| 44389 | COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE |
| 44390 | COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF FOREIGN BODY |
| 44391 | COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) |
| 44392 | COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY |
| 44393 | COLONOSCOPY THROUGH STOMA; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE |
| 44394 | COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE |
| 44397 | COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) |
| 45330 | SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) |
| 45331 | SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE |
| 45332 | SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY |
| 45333 | SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY |
| 45334 | SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) |
| 45335 | SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE |
| 45337 | SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION OF VOLVULUS, ANY METHOD |
| 45338 | SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE |
| 45339 | SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE |
| 45340 | SIGMOIDOSCOPY, FLEXIBLE; WITH DILATION BY BALLOON, 1 OR MORE STRICTURES |
| 45341 | SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION |
| 45342 | SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) |
| 45345 | SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) |
| 45355 | COLONOSCOPY, RIGID OR FLEXIBLE, TRANSABDOMINAL VIA COLOTOMY, SINGLE OR MULTIPLE |
| 45378 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WITH OR WITHOUT COLON DECOMPRESSION (SEPARATE PROCEDURE) |
| 45379 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF FOREIGN BODY |
| 45380 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH BIOPSY, SINGLE OR MULTIPLE |
| 45381 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE |
| 45382 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) |
| 45383 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE |
| 45384 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY |
| 45385 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE |
| 45386 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH DILATION BY BALLOON, 1 OR MORE STRICTURES |
| 45387 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) |
| 45391 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION |
| 45392 | COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) |
ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity
| 006.1 | CHRONIC INTESTINAL AMEBIASIS WITHOUT ABSCESS |
| 006.2 | AMEBIC NONDYSENTERIC COLITIS |
| 006.9 | AMEBIASIS UNSPECIFIED |
| 008.04 | INTESTINAL INFECTION DUE TO ENTEROHEMORRHAGIC E. COLI |
| 008.43 | INTESTINAL INFECTION DUE TO CAMPYLOBACTER |
| 008.45 | INTESTINAL INFECTION DUE TO CLOSTRIDIUM DIFFICILE |
| 009.0 - 009.3 | INFECTIOUS COLITIS ENTERITIS AND GASTROENTERITIS - DIARRHEA OF PRESUMED INFECTIOUS ORIGIN |
| 014.00 - 014.86 | TUBERCULOUS PERITONITIS UNSPECIFIED EXAMINATION - OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) |
| 041.02 | STREPTOCOCCUS INFECTION IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE STREPTOCOCCUS GROUP B |
| 041.04 | STREPTOCOCCUS INFECTION IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE STREPTOCOCCUS GROUP D [ENTEROCOCCUS] |
| 042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
| 153.0 - 153.9 | MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE |
| 154.0 - 154.8 | MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION - MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS |
| 159.0 | MALIGNANT NEOPLASM OF INTESTINAL TRACT PART UNSPECIFIED |
| 159.8 | MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE SYSTEM AND INTRA-ABDOMINAL ORGANS |
| 195.3 | MALIGNANT NEOPLASM OF PELVIS |
| 196.2 | SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA-ABDOMINAL LYMPH NODES |
| 197.5 | SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM |
| 197.6 | SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM |
| 197.7 | MALIGNANT NEOPLASM OF LIVER SECONDARY |
| 199.0 | DISSEMINATED MALIGNANT NEOPLASM |
| 209.10 - 209.17 | MALIGNANT CARCINOID TUMOR OF THE LARGE INTESTINE, UNSPECIFIED PORTION - MALIGNANT CARCINOID TUMOR OF THE RECTUM |
| 209.50 - 209.57 | BENIGN CARCINOID TUMOR OF THE LARGE INTESTINE, UNSPECIFIED PORTION - BENIGN CARCINOID TUMOR OF THE RECTUM |
| 209.67 | BENIGN CARCINOID TUMOR OF HINDGUT, NOT OTHERWISE SPECIFIED |
| 211.3 | BENIGN NEOPLASM OF COLON |
| 211.4 | BENIGN NEOPLASM OF RECTUM AND ANAL CANAL |
| 230.0 - 230.6 | CARCINOMA IN SITU OF LIP ORAL CAVITY AND PHARYNX - CARCINOMA IN SITU OF ANUS UNSPECIFIED |
| 235.2 | NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM |
| 235.5 | NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED DIGESTIVE ORGANS |
| 239.0 | NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM |
| 280.0 | IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC) |
| 280.9 | IRON DEFICIENCY ANEMIA UNSPECIFIED |
| 421.0 | ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS |
| 448.0 | HEREDITARY HEMORRHAGIC TELANGIECTASIA |
| 538 | GASTROINTESTINAL MUCOSITIS (ULCERATIVE) |
| 555.0 - 555.9 | REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE |
| 556.0 - 556.9 | ULCERATIVE (CHRONIC) ENTEROCOLITIS - ULCERATIVE COLITIS UNSPECIFIED |
| 557.0 - 557.9 | ACUTE VASCULAR INSUFFICIENCY OF INTESTINE - UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE |
| 558.1 - 558.3 | GASTROENTERITIS AND COLITIS DUE TO RADIATION - ALLERGIC GASTROENTERITIS AND COLITIS |
| 558.42 | EOSINOPHILIC COLITIS |
| 558.9 | OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS |
| 560.0 | INTUSSUSCEPTION |
| 560.1 | PARALYTIC ILEUS |
| 560.2 | VOLVULUS |
| 560.81 | INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) (POSTINFECTION) |
| 560.89 | OTHER SPECIFIED INTESTINAL OBSTRUCTION |
| 560.9 | UNSPECIFIED INTESTINAL OBSTRUCTION |
| 562.10 - 562.13 | DIVERTICULOSIS OF COLON (WITHOUT HEMORRHAGE) - DIVERTICULITIS OF COLON WITH HEMORRHAGE |
| 564.4 - 564.89 | OTHER POSTOPERATIVE FUNCTIONAL DISORDERS - OTHER FUNCTIONAL DISORDERS OF INTESTINE |
| 569.0 | ANAL AND RECTAL POLYP |
| 569.3 | HEMORRHAGE OF RECTUM AND ANUS |
| 569.81 - 569.89 | FISTULA OF INTESTINE EXCLUDING RECTUM AND ANUS - OTHER SPECIFIED DISORDERS OF INTESTINES |
| 578.1 | BLOOD IN STOOL |
| 578.9 | HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED |
| 596.1 | INTESTINOVESICAL FISTULA |
| 619.1 | DIGESTIVE-GENITAL TRACT FISTULA FEMALE |
| 701.2 | ACQUIRED ACANTHOSIS NIGRICANS |
| 759.6 | OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED |
| 787.91 | DIARRHEA |
| 787.99 | OTHER SYMPTOMS INVOLVING DIGESTIVE SYSTEM |
| 792.1 | NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS |
| 793.4 | NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT |
| 936 | FOREIGN BODY IN INTESTINE AND COLON |
| 937 | FOREIGN BODY IN ANUS AND RECTUM |
| V10.00 | PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN GASTROINTESTINAL TRACT |
| V10.03 - V10.07 | PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LIVER |
| V12.70 | PERSONAL HISTORY OF UNSPECIFIED DIGESTIVE DISEASE |
| V12.72 | PERSONAL HISTORY OF COLONIC POLYPS |
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
NA
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
The medical record should support the medical reasonableness, necessity and frequency of the diagnostic test performed. This documentation should be made available to the Contractor upon request
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Appendices
Utilization Guidelines
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice
Sources of Information and Basis for Decision
American Society for Gastrointestinal Endoscopy (ASGE):
ASGE. "Appropriate Use of Gastrointestinal Endoscopy." Gastrointestinal Endoscopy 2000; 52:831-837
ASGE. The Role of Endoscopy in The Patient With Lower Gastrointestinal Bleeding. Gastrointestinal Endoscopy 1988; 34 (Suppl): 235-255.
ASGE. The Role of Colonoscopy in The Management of Patients With Inflammatory Bowel Disease. Gastrointestinal Endoscopy 1988; 34 (Suppl): 105-115.
ASGE. Colorectal Cancer Screening and Surveillance. Gastrointestinal Endoscopy 2000; 51: 777-782.
Blijlevens NM. Current Opinion Support Palliative Care. 2007 April: 1(1):16-22
Douglas K. Rex, MD; Charles J. Kahi, MD et. al. Guidelines for Colonoscopy Surveillance after Cancer Resection: A Consensus Update by the American Cancer Society and US Multi-Society
Task Force on Colorectal Cancer, CA Cancer J Clin 2006; 56; 160-167
Fernandes ER, PagiliariC, Tuon FF, de Andrade Junior HF, Averbach M, Duarte MI. Chronic colitis associated with HIV infection can be related to intraepithelial infiltration of the colon by CD8+ T lymphocytes. International Journal of STD and AIDS. 2008, August; 19 (8):524-8
Hanauer, S.B, Sandborn, W. Management of Crohns Disease in Adults. American Journal of Gastroenterology March 2001, Volume 96, Number 3 pp 635-643.
Stollman, N.H., Raskin, J.B. Diagnosis and Management of Diverticular Disease of the Colon in Adults. American Journal of Gastroenterology Nov 1999, Volume 92, Number 11, pp 3110-3121.
Vaska VL, Faoagali JL. €œStreptococcus bovis bacteraemia: Identification within organism complex and association with endocarditis and colonic malignancy, Pathology, 2008 October 29:1-4
Winawer, Zauber, Fletcher et al. Guidelines for Colonoscopy Surveillance after Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. CA Cancer J Clin 2006; May-Jun.; 56(3):143-59
Carrier Medical Directors Workgroup,
Other Contractors Medicare Policies
ASGE. "Appropriate Use of Gastrointestinal Endoscopy." Gastrointestinal Endoscopy 2000; 52:831-837
ASGE. The Role of Endoscopy in The Patient With Lower Gastrointestinal Bleeding. Gastrointestinal Endoscopy 1988; 34 (Suppl): 235-255.
ASGE. The Role of Colonoscopy in The Management of Patients With Inflammatory Bowel Disease. Gastrointestinal Endoscopy 1988; 34 (Suppl): 105-115.
ASGE. Colorectal Cancer Screening and Surveillance. Gastrointestinal Endoscopy 2000; 51: 777-782.
Blijlevens NM. Current Opinion Support Palliative Care. 2007 April: 1(1):16-22
Douglas K. Rex, MD; Charles J. Kahi, MD et. al. Guidelines for Colonoscopy Surveillance after Cancer Resection: A Consensus Update by the American Cancer Society and US Multi-Society
Task Force on Colorectal Cancer, CA Cancer J Clin 2006; 56; 160-167
Fernandes ER, PagiliariC, Tuon FF, de Andrade Junior HF, Averbach M, Duarte MI. Chronic colitis associated with HIV infection can be related to intraepithelial infiltration of the colon by CD8+ T lymphocytes. International Journal of STD and AIDS. 2008, August; 19 (8):524-8
Hanauer, S.B, Sandborn, W. Management of Crohns Disease in Adults. American Journal of Gastroenterology March 2001, Volume 96, Number 3 pp 635-643.
Stollman, N.H., Raskin, J.B. Diagnosis and Management of Diverticular Disease of the Colon in Adults. American Journal of Gastroenterology Nov 1999, Volume 92, Number 11, pp 3110-3121.
Vaska VL, Faoagali JL. €œStreptococcus bovis bacteraemia: Identification within organism complex and association with endocarditis and colonic malignancy, Pathology, 2008 October 29:1-4
Winawer, Zauber, Fletcher et al. Guidelines for Colonoscopy Surveillance after Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. CA Cancer J Clin 2006; May-Jun.; 56(3):143-59
Carrier Medical Directors Workgroup,
Other Contractors Medicare Policies
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin: 01/16/2009
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2009
J-5 MAC (IA,KS,MO, NE 02/12/2009
Jurisdictional Open meeting
12/17/08
Wisconsin: 01/16/2009
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2009
J-5 MAC (IA,KS,MO, NE 02/12/2009
Jurisdictional Open meeting
12/17/08
Start Date of Comment Period
02/12/2009
End Date of Comment Period
07/05/2009
Start Date of Notice Period
08/01/2009
Revision History Number
X
Revision History Explanation
09/16/2009 Changed title from "Diagnostic Sigmoidoscopy and Colonoscopy" to "Colonoscopy and Sigmoidoscopy-Diagnostic".
08/12/2009 Revised order of items in Indicaitons and Limitations section.
07/25/2009 Final revisions to draft. Released to Final. Replaces L26644, L19702, L19703, L19704, L19705
8/1/09 as revision effective date because contractor number that was removed, 05392, terminates and joins with W MO on that date.
08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.
8/10/2009 - The description for Revenue code 0760 was changed
8/10/2009 - The description for Revenue code 0761 was changed
8/10/2009 - The description for Revenue code 0762 was changed
8/10/2009 - The description for Revenue code 0769 was changed
04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 14 was changed
8/1/2010 - The description for Bill Type Code 71 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0320 was changed
8/1/2010 - The description for Revenue code 0321 was changed
8/1/2010 - The description for Revenue code 0322 was changed
8/1/2010 - The description for Revenue code 0323 was changed
8/1/2010 - The description for Revenue code 0324 was changed
8/1/2010 - The description for Revenue code 0329 was changed
8/1/2010 - The description for Revenue code 0360 was changed
8/1/2010 - The description for Revenue code 0361 was changed
8/1/2010 - The description for Revenue code 0362 was changed
8/1/2010 - The description for Revenue code 0367 was changed
8/1/2010 - The description for Revenue code 0369 was changed
8/1/2010 - The description for Revenue code 0450 was changed
8/1/2010 - The description for Revenue code 0490 was changed
8/1/2010 - The description for Revenue code 0499 was changed
8/1/2010 - The description for Revenue code 0510 was changed
8/1/2010 - The description for Revenue code 0511 was changed
8/1/2010 - The description for Revenue code 0512 was changed
8/1/2010 - The description for Revenue code 0513 was changed
8/1/2010 - The description for Revenue code 0514 was changed
8/1/2010 - The description for Revenue code 0515 was changed
8/1/2010 - The description for Revenue code 0516 was changed
8/1/2010 - The description for Revenue code 0517 was changed
8/1/2010 - The description for Revenue code 0519 was changed
8/1/2010 - The description for Revenue code 0520 was changed
8/1/2010 - The description for Revenue code 0521 was changed
8/1/2010 - The description for Revenue code 0522 was changed
8/1/2010 - The description for Revenue code 0523 was changed
8/1/2010 - The description for Revenue code 0524 was changed
8/1/2010 - The description for Revenue code 0525 was changed
8/1/2010 - The description for Revenue code 0526 was changed
8/1/2010 - The description for Revenue code 0527 was changed
8/1/2010 - The description for Revenue code 0528 was changed
8/1/2010 - The description for Revenue code 0529 was changed
8/1/2010 - The description for Revenue code 0750 was changed
8/1/2010 - The description for Revenue code 0760 was changed
8/1/2010 - The description for Revenue code 0761 was changed
8/1/2010 - The description for Revenue code 0762 was changed
8/1/2010 - The description for Revenue code 0769 was changed
8/1/2010 - Revenue code 0759 was deleted
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
44393 descriptor was changed in Group 1
45381 descriptor was changed in Group 1
01/14/2011 Annual review no change in coverage.
02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
03/01/2012- Annual review, no change to the LCD;
08/12/2009 Revised order of items in Indicaitons and Limitations section.
07/25/2009 Final revisions to draft. Released to Final. Replaces L26644, L19702, L19703, L19704, L19705
8/1/09 as revision effective date because contractor number that was removed, 05392, terminates and joins with W MO on that date.
08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.
8/10/2009 - The description for Revenue code 0760 was changed
8/10/2009 - The description for Revenue code 0761 was changed
8/10/2009 - The description for Revenue code 0762 was changed
8/10/2009 - The description for Revenue code 0769 was changed
04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 14 was changed
8/1/2010 - The description for Bill Type Code 71 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0320 was changed
8/1/2010 - The description for Revenue code 0321 was changed
8/1/2010 - The description for Revenue code 0322 was changed
8/1/2010 - The description for Revenue code 0323 was changed
8/1/2010 - The description for Revenue code 0324 was changed
8/1/2010 - The description for Revenue code 0329 was changed
8/1/2010 - The description for Revenue code 0360 was changed
8/1/2010 - The description for Revenue code 0361 was changed
8/1/2010 - The description for Revenue code 0362 was changed
8/1/2010 - The description for Revenue code 0367 was changed
8/1/2010 - The description for Revenue code 0369 was changed
8/1/2010 - The description for Revenue code 0450 was changed
8/1/2010 - The description for Revenue code 0490 was changed
8/1/2010 - The description for Revenue code 0499 was changed
8/1/2010 - The description for Revenue code 0510 was changed
8/1/2010 - The description for Revenue code 0511 was changed
8/1/2010 - The description for Revenue code 0512 was changed
8/1/2010 - The description for Revenue code 0513 was changed
8/1/2010 - The description for Revenue code 0514 was changed
8/1/2010 - The description for Revenue code 0515 was changed
8/1/2010 - The description for Revenue code 0516 was changed
8/1/2010 - The description for Revenue code 0517 was changed
8/1/2010 - The description for Revenue code 0519 was changed
8/1/2010 - The description for Revenue code 0520 was changed
8/1/2010 - The description for Revenue code 0521 was changed
8/1/2010 - The description for Revenue code 0522 was changed
8/1/2010 - The description for Revenue code 0523 was changed
8/1/2010 - The description for Revenue code 0524 was changed
8/1/2010 - The description for Revenue code 0525 was changed
8/1/2010 - The description for Revenue code 0526 was changed
8/1/2010 - The description for Revenue code 0527 was changed
8/1/2010 - The description for Revenue code 0528 was changed
8/1/2010 - The description for Revenue code 0529 was changed
8/1/2010 - The description for Revenue code 0750 was changed
8/1/2010 - The description for Revenue code 0760 was changed
8/1/2010 - The description for Revenue code 0761 was changed
8/1/2010 - The description for Revenue code 0762 was changed
8/1/2010 - The description for Revenue code 0769 was changed
8/1/2010 - Revenue code 0759 was deleted
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
44393 descriptor was changed in Group 1
45381 descriptor was changed in Group 1
01/14/2011 Annual review no change in coverage.
02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
03/01/2012- Annual review, no change to the LCD;
Reason for Change
Maintenance (annual review with new changes, formatting, etc.)
Related Documents
This LCD has no Related Documents.
LCD Attachments
NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now.
Page Last Updated: Thursday, 01-Mar-2012 12:38:20 CST
Home |
Web Help |
Feedback |
About WPS
© Wisconsin Physicians Service Insurance Corporation | All Rights Reserved
Privacy Statement | Legal Disclaimer
