L29152-LCD

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Automated World Health

Local Coverage Determination (LCD) for Diagnostic Colonoscopy (L29152)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29152

LCD Title Diagnostic Colonoscopy

Contractor's Determination Number 44388

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2010

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Program Memorandum, CMS Transmittal AB-03-114, Change Request 2822, dated 08/01/03

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Section 100.2

Indications and Limitations of Coverage and/or Medical Necessity

Colonoscopy allows direct visual examination of the intestinal tract with a flexible tube containing light transmitting glass fibers that return a magnified image. Colonoscopy can act as both a diagnostic and therapeutic tool in the same procedure. Therapeutic indications include removal of polyps or foreign bodies, hemostasis by coagulation, and removal of tumors.

Medicare will consider a colonoscopy to be medically necessary under any of the following circumstances (see the “ ICD-9 Codes That Support Medical Necessity” section of this policy):

• Evaluation of an abnormality on barium enema which is likely to be clinically significant, such as a filling defect or stricture.

• Evaluation and excision of polyps detected by barium enema or flexible sigmoidoscopy.

• Evaluation of unexplained gastrointestinal bleeding; hematochezia not thought to be from rectum or perianal source, melena of unknown origin, or presence of fecal occult blood.

• Unexplained iron deficiency anemia.

• Examination to evaluate the entire colon for simultaneous cancer or neoplastic polyps in a patient with a treatable cancer or neoplastic polyp.

• Evaluation of a patient with carcinoma of the colon before bowel resection. Post surgical follow-up should be conducted annually for 2 years and every 2 years thereafter.

• Yearly evaluation with multiple biopsies for detection of cancer and dysplasia for patients with chronic ulcerative colitis who have had pancolitis of greater than seven years duration.

• Yearly evaluation with multiple biopsies for detection of cancer and dysplasia for patients with chronic ulcerative colitis who have had left-sided colitis of over 15 years duration (not indicated for disease limited to rectosigmoid).

• Chronic inflammatory bowel disease of the colon when more precise diagnosis or determination of the extent of activity of disease will influence immediate management.

• Clinically significant diarrhea of unexplained origin.

• Treatment of bleeding from such lesions as vascular anomalies, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).

• Foreign body removal.

• Decompression of acute non-toxic megacolon.

• Balloon dilation of stenotic lesions (e.g., anastomotic strictures).

• Decompression of colonic volvulus.

• Examination and evaluation when a change in management is probable or is being suspected based on results of the colonoscopy.

• 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.

• If a total colonoscopy is unsuccessful preoperatively due to obstructive cancer, repeat colonoscopy 3-6 months post-operatively unless unresectable metastases are found at surgery.

• Evaluation to differentiate between ulcerative and Crohn's colitis.

• Evaluation 3 years after resection of newly diagnosed small (< 5mm diameter) adenomatous polyps when only

a single polyp was detected. After 1 negative 3-year follow-up examination subsequent surveillance intervals may be increased to 5 years.

• Evaluation at 1 and 4 year intervals after resection of multiple or large (> 10mm) adenomalous polyps. Subsequent surveillance intervals may then be increased to every 5 years.

• Evaluation of low to high grade dysplasia in flat mucosa by colonoscopy 6 months after undergoing aggressive medical therapy, especially when inflammatory changes were present.

• Evaluation in 1 year after the removal of multiple adenomas. If examination proves negative then repeat in 3 years. After 1 negative 3-year follow-up examination, repeat exam every 5 years.

• Evaluation of a patient presenting with signs/symptoms (e.g., rectal bleeding, abdominal pain) of a disorder that appears to be related to the colon.

When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy at a rate consistent with that of a flexible sigmoidoscopy as long as coverage conditions are met for the incomplete procedure. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met.

For screening colonoscopies, refer to Medicare’s Local Coverage Determination G0104 (Colorectal Cancer Screening).

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.

Revenue 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.

99999 Not Applicable

CPT/HCPCS Codes

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)

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

COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH CONTROL OF BLEEDING (EG, 45382 INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA

COAGULATOR)

COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH ABLATION OF TUMOR(S), POLYP(S), 45383 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

009.0 - 009.1

INFECTIOUS COLITIS ENTERITIS AND GASTROENTERITIS - COLITIS ENTERITIS AND GASTROENTERITIS OF PRESUMED INFECTIOUS ORIGIN

009.3 DIARRHEA OF PRESUMED INFECTIOUS ORIGIN

038.9 UNSPECIFIED SEPTICEMIA

152.2 MALIGNANT NEOPLASM OF ILEUM

153.0 - 153.9

154.0 - 154.8

MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

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

155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

176.3 KAPOSI'S SARCOMA GASTROINTESTINAL SITES

195.2 MALIGNANT NEOPLASM OF ABDOMEN

197.0 SECONDARY MALIGNANT NEOPLASM OF LUNG

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

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

199.1 DISSEMINATED MALIGNANT NEOPLASM

199.2 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE

199.3 MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN

201.90 HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE

211.2 BENIGN NEOPLASM OF DUODENUM JEJUNUM AND ILEUM

211.3 BENIGN NEOPLASM OF COLON

211.4 BENIGN NEOPLASM OF RECTUM AND ANAL CANAL

211.8 BENIGN NEOPLASM OF RETROPERITONEUM AND PERITONEUM

230.3 CARCINOMA IN SITU OF COLON

230.4 CARCINOMA IN SITU OF RECTUM

230.5 CARCINOMA IN SITU OF ANAL CANAL

230.6 CARCINOMA IN SITU OF ANUS UNSPECIFIED

230.9 CARCINOMA IN SITU OF OTHER AND UNSPECIFIED DIGESTIVE ORGANS

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

281.9 UNSPECIFIED DEFICIENCY ANEMIA

448.0 HEREDITARY HEMORRHAGIC TELANGIECTASIA

555.0 - 555.9

556.0 - 556.9

REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE

ULCERATIVE (CHRONIC) ENTEROCOLITIS - ULCERATIVE COLITIS UNSPECIFIED

557.0 - 557.9

558.1 - 558.9

ACUTE VASCULAR INSUFFICIENCY OF INTESTINE - UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE

GASTROENTERITIS AND COLITIS DUE TO RADIATION - OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS

560.1 INTUSSUSCEPTION

560.2 PARALYTIC ILEUS

560.3 VOLVULUS

560.30 - 560.39 IMPACTION OF INTESTINE UNSPECIFIED - OTHER IMPACTION OF INTESTINE

560.81 - 560.89

INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) (POSTINFECTION) - OTHER SPECIFIED INTESTINAL OBSTRUCTION

560.9 UNSPECIFIED INTESTINAL OBSTRUCTION

562.11 DIVERTICULITIS OF COLON (WITHOUT HEMORRHAGE)

562.12 DIVERTICULOSIS OF COLON WITH HEMORRHAGE

562.13 DIVERTICULITIS OF COLON WITH HEMORRHAGE

564.1 - 564.09 UNSPECIFIED CONSTIPATION - OTHER CONSTIPATION

564.2 IRRITABLE BOWEL SYNDROME

564.4 OTHER POSTOPERATIVE FUNCTIONAL DISORDERS

564.5 FUNCTIONAL DIARRHEA

564.7 MEGACOLON OTHER THAN HIRSCHSPRUNG'S

564.81 - 564.89 NEUROGENIC BOWEL - OTHER FUNCTIONAL DISORDERS OF INTESTINE

569.0 ANAL AND RECTAL POLYP

569.3 HEMORRHAGE OF RECTUM AND ANUS

569.41 ULCER OF ANUS AND RECTUM

569.43 ANAL SPHINCTER TEAR (HEALED) (OLD)

569.44 DYSPLASIA OF ANUS

569.49 OTHER SPECIFIED DISORDERS OF RECTUM AND ANUS

569.5 ABSCESS OF INTESTINE

569.60 - 569.69

569.71 - 569.79

COLOSTOMY AND ENTEROSTOMY COMPLICATION UNSPECIFIED - OTHER COLOSTOMY AND ENTEROSTOMY COMPLICATION

POUCHITIS - OTHER COMPLICATIONS OF INTESTINAL POUCH

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

783.21 LOSS OF WEIGHT

787.3 FLATULENCE ERUCTATION AND GAS PAIN

787.60 - 787.63 FULL INCONTINENCE OF FECES - FECAL URGENCY

787.91 - 787.99 DIARRHEA - OTHER SYMPTOMS INVOLVING DIGESTIVE SYSTEM

789.00 - 789.09 ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN OTHER SPECIFIED SITE

789.30 - 789.39

789.60 - 789.69

ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE

ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL TENDERNESS OTHER SPECIFIED SITE

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

V10.05 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE

V10.06 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

V12.72 PERSONAL HISTORY OF COLONIC POLYPS

V16.0 FAMILY HISTORY OF MALIGNANT NEOPLASM OF GASTROINTESTINAL TRACT

V18.51 - V18.59

V76.50 - V76.52

FAMILY HISTORY, COLONIC POLYPS - FAMILY HISTORY, OTHER DIGESTIVE DISORDERS

SPECIAL SCREENING FOR MALIGNANT NEOPLASMS UNSPECIFIED INTESTINE - SPECIAL SCREENING FOR MALIGNANT NEOPLASMS SMALL INTESTINE

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation (office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the colonoscopy procedure covered by the Medicare program. The procedure results/report and any associated pathology report must be included in the patient's medical record.

If the provider of the colonoscopy is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of procedure results/report and pathology report along with copies of the ordering/referring physician's order for the procedure.

The patient’s medical record should contain documentation to support an incomplete procedure.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Practice Parameters Committee of the American College of Gastroenterology

The American Journal of Gastroenterology The New England Journal of Medicine

The U.S. Preventive Services Task Force, Washington, D.C. Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups,

which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted ICD-9-CM code 787.6. Added ICD-9-CM code range 787.60-787.63. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR B2009-098

September 2009 Update

Explanation of Revision: Annual 2010 ICD-9-CM Update. Added new diagnosis codes 569.71-569.79. Revised descriptor for diagnosis code 793.4. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-044FL

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29152) replaces LCD L6057 as the policy in notice. This document (L29152) is effective on 02/02/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

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

Reason for Change