LCD/NCD Portal

L29118 COMPUTED TOMOGRAPHIC COLONOGRAPHY

 

 

06/14/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Medicare will consider CT colonography medically reasonable and necessary:

 

• When an instrument colonoscopy of the entire colon is incomplete due to an obstructing lesion suspected of being an obstructing neoplasm.

• When the intent of the study is to identify a lesion suspected of being an obstructing neoplasm, even if the final diagnosis suggests that the lesion is due to scarring from previous surgery, extrinsic compression aberrant anatomy, or unsuspected diverticulitis.

• When the patient has an uncorrectable coagulopathy or is on anticoagulant therapy that cannot be safely discontinued and the primary physician and the colonographer agree that there is an increased risk.

o When performing CT colonography for this indication, ONE of the previous two indications must also be documented.

• When utilizing equipment which will provide optimal performance such as a CT scanner which includes:

o A multi-detector scanner with a maximum collimation of 5mm.

o 2.5mm reconstruction interval.

o Scan time that should not produce a breath hold interval over 25 seconds.

• When performed only by providers of gastroenterology and radiology services or other providers who have specialized training and expertise in performing CT colonography.

• A qualified physician for this service/procedure is defined as follows:

o A) Physician is properly enrolled in Medicare.

o B) Training and expertise must have been acquired within the framework of

 An accredited residency.

 Fellowship program in the applicable specialty/subspecialty in the United States.

 Must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

CT colonography will NOT be covered for the following:

• When CT colonography is performed without a prior incomplete colonoscopy due to the indications as outlined in this LCD.

• When used as an alternative to fiberoptic colonoscopy, for screening or in the absence of signs or symptoms of disease.

• When used as an alternative to fiberoptic colonoscopy, even though performed for signs or symptoms of disease.

• When used for screening, in the absence of signs or symptoms of disease, regardless of family history or other risk factors for the development of colonic disease.

 

 

CPT/HCPCS Codes

 

74261 COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRAST MATERIAL

 

74262 COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH CONTRAST MATERIAL(S) INCLUDING NON-CONTRAST IMAGES, IF PERFORMED

 

 

ICD-9 Codes that Support Medical Necessity

 

153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE

153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON

153.2 MALIGNANT NEOPLASM OF DESCENDING COLON

153.3 MALIGNANT NEOPLASM OF SIGMOID COLON

153.6 MALIGNANT NEOPLASM OF ASCENDING COLON

153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE

154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION

154.1 MALIGNANT NEOPLASM OF RECTUM

154.2 MALIGNANT NEOPLASM OF ANAL CANAL

154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE

154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

211.3 BENIGN NEOPLASM OF COLON

211.4 BENIGN NEOPLASM OF RECTUM AND ANAL CANAL

560.0 INTUSSUSCEPTION

560.2 VOLVULUS

560.81 INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) (POSTINFECTION)

560.89 OTHER SPECIFIED INTESTINAL OBSTRUCTION

560.9 UNSPECIFIED INTESTINAL OBSTRUCTION

 

 

Documentation Requirements

 

• The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, reason for the test, and interpretive report and copies of all images obtained.

o The computerized data with image reconstruction should also be maintained.

• The medical record must contain documentation, including a written or electronic request for the procedure which fully supports the medical necessity of the procedure performed.

o This documentation includes, but is not limited to relevant medical history, physical examination, diagnosis (if known), pertinent signs and symptoms and results of pertinent diagnostic tests and/or procedures.

o This entire documentation-not just the test report or the findings/diagnosis on the order, must be made available to Medicare upon request.

• Documentation must be made available to Medicare upon request.

o The order/prescription form of the referring physician must be retained in the medical record.

o The results of a fiberoptic colonoscopy performed prior to the CT colonography, which was incomplete due to obstruction must be retained in the medical record.

o Documentation should clearly indicate cause of obstruction.

o Documentation should support the technology used to perform the CT colonoscopy.

o When performing CT colonoscopy in lieu of conventional colonoscopy due to an uncorrectable coagulopathy or anticoagulant therapy that cannot be safely discontinued, documentation must clearly support that one of the indications as outlined in bullets #1 or #2 in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this LCD.

 

 

Utilization Guidelines

 

• It is expected that the physician who performed the failed colonoscopy will order the CT colonography.

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

• It is expected that only trained qualified physicians, as defined in the Indications and Limitations section of this LCD, will perform CT colonography.

• CT colonography is never covered for screening.

Treatment Logic:

• Computed tomographic colonography (CT colonography) also known as virtual colonoscopy is a technique used for the detection of colorectal polyps.

• There are two approaches currently utilized for CT colonography.

• The first approach uses 2-D images with direct 3-D reconstruction for problem areas.

• The second approach utilizes 3-D endoscopic navigation of the colon with the 2-D images used for confirmation and problem solving.

 

 

Sources of Information and Basis for Decision

 

ACR Practice Guideline for the Performance of Computed Tomography (CT) Colonography in Adults. (Oct. 2005) Retrieved from website August 2, 2006. http://www.acr.org

 

ACR Practice Guideline for performing and interpreting diagnostic computed tomography (CT) (2006). Retrieved from http://www.acr.org

 

ACR Practice Guideline for communication of diagnostic imaging findings (2010). Retrieved from http://www.acr.org

 

Barish, M.A and Rocha, T.C., Multislice CT colonography: current status and limitations. Radiologic Clinics of North America 43; 6.

 

Cappell, M.S., Koch, S., Lefkovitz, Z., et al. (2005). The emerging role of virtual colonoscopy. Medical Clinic of North America, 89:111-128.

 

Cotton, P.B., Durkalski, V.L., Pineau, B.C., et al. (2004) Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. Journal of American Medical Association; 291:1713-1719.

 

FCSO LCD 29118, Computed Tomographic Colonography, 06/14/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Hara, A.K., Johnson, C.D., et al. (2001) CT Colonography: single – versus multi-detector row imaging. Radiology, 2001; 219: 461-465.

 

Laghi, A., Iannacone, R., et al. (2002). Detection of colorectal lesions with virtual computed tomographic colonography. American Journal of Surgery 183; 124-131.

 

Mark, D., Aronson, N., et al. (2004). Executive Summary. CT Colonoscopy (“Virtual colonoscopy”) for colon cancer screening. Technology Evaluation Center. Blue Cross Blue Shield Association.

 

Orellana, C. (2004) New study supports use of virtual colonoscopy. The Lancet Oncology. 5(1). Retrieved February 22, 2005 from MD Consult database (449871345-Z).

 

Pickhardt, P.J., Choi, J.R., Hwang, I., Butler, J.A., Puckett, M.L., Hildebrandt, H.A., et al.(2003) Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. New England Journal of Medicine, 349:2131-200

 

Pickhardt, P.J. (2004) Virtual colonoscopy. Journal of American Medical Association, 292: 431-431

 

Pickhardt, P.J., Lee, A.D., et al (2005) Linear polyp measurement at CT colonography: in vitro and in vivo comparison of two-dimensional and three-dimensional displays. Radiology 2005; 236:872-878. Abstract.

 

Pickhardt, P.J. (2003) Three-dimensional endoluminal CT colonography (virtual colonography): comparison of three commercially available systems. AJR 2003; 181: 1599-1606.

 

Ransohoff, D.F. (2004) Virtual colonoscopy-what it can do vs. what it will do. JAMA 291: 1772-1774.

 

Wellbery, C., (2005) Virtual colonoscopy vs. routine colonoscopy. Retrieved February 23, 2005, from findarticles data base (ai_n8702969)

 

Zepf, B. (2004) Is there a wider role for virtual colonoscopy? Retrieved February 23, 2005, from findarticles data base(ai_n6048582)

 

 

AMA CPT / ADA CDT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2011 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.

 

CMS LCD COMPUTED TOMOGRAPHIC COLONOGRAPHY