LCD/NCD Portal

L29152

 

DIAGNOSTIC COLONOSCOPY

 

10/01/2010

 

Indications and Limitations of Coverage and/or Medical Necessity

 

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:

o Hematochezia not thought to be from rectum or perianal source.

o Melena of unknown origin.

o 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.

o 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 (e.g., electrocoagulation, heater probe, laser, or injection therapy.)

o Vascular anomalies.

o Ulceration.

o Neoplasia.

o Polypectomy site.

• 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.

o If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 MONTHS.

o 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.

o After one 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.

o 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.

o If examination proves negative then repeat in 3 YEARS.

o After one 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.)

 

 

Documentation 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.

o 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.

 

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

 

 

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

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

 

009.0 INFECTIOUS COLITIS ENTERITIS AND GASTROENTERITIS

009.1 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 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

153.4 MALIGNANT NEOPLASM OF CECUM

153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS

153.6 MALIGNANT NEOPLASM OF ASCENDING COLON

153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE

153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE

153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

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

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

199.0 DISSEMINATED MALIGNANT NEOPLASM

199.1 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE

199.2 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 REGIONAL ENTERITIS OF SMALL INTESTINE

555.1 REGIONAL ENTERITIS OF LARGE INTESTINE

555.2 REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE

555.9 REGIONAL ENTERITIS OF UNSPECIFIED SITE

556.0 ULCERATIVE (CHRONIC) ENTEROCOLITIS

556.1 ULCERATIVE (CHRONIC) ILEOCOLITIS

556.2 ULCERATIVE (CHRONIC) PROCTITIS

556.3 ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS

556.4 PSEUDOPOLYPOSIS OF COLON

556.5 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS

556.6 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS

556.8 OTHER ULCERATIVE COLITIS

556.9 ULCERATIVE COLITIS UNSPECIFIED

557.0 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE

557.1 CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE

557.9 UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE

558.1 GASTROENTERITIS AND COLITIS DUE TO RADIATION

558.2 TOXIC GASTROENTERITIS AND COLITIS

558.3 ALLERGIC GASTROENTERITIS AND COLITIS

558.41 EOSINOPHILIC GASTROENTERITIS

558.42 EOSINOPHILIC COLITIS

558.9 OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS

560.0 INTUSSUSCEPTION

560.1 PARALYTIC ILEUS

560.2 VOLVULUS

560.30 IMPACTION OF INTESTINE UNSPECIFIED

560.31 GALLSTONE ILEUS

560.32 FECAL IMPACTION

560.39 OTHER IMPACTION OF INTESTINE

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

560.89 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

564.00 UNSPECIFIED CONSTIPATION

564.01 SLOW TRANSIT CONSTIPATION

564.02 OUTLET DYSFUNCTION CONSTIPATION

564.09 OTHER CONSTIPATION

564.1 IRRITABLE BOWEL SYNDROME

564.4 OTHER POSTOPERATIVE FUNCTIONAL DISORDERS

564.5 FUNCTIONAL DIARRHEA

564.7 MEGACOLON OTHER THAN HIRSCHSPRUNG'S

564.81 NEUROGENIC BOWEL

564.89 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 COLOSTOMY AND ENTEROSTOMY COMPLICATION UNSPECIFIED

569.61 INFECTION OF COLOSTOMY OR ENTEROSTOMY

569.62 MECHANICAL COMPLICATION OF COLOSTOMY AND ENTEROSTOMY

569.69 OTHER COLOSTOMY AND ENTEROSTOMY COMPLICATION

569.71 POUCHITIS

569.79 OTHER COMPLICATIONS OF INTESTINAL POUCH

569.81 FISTULA OF INTESTINE EXCLUDING RECTUM AND ANUS

569.82 ULCERATION OF INTESTINE

569.83 PERFORATION OF INTESTINE

569.84 ANGIODYSPLASIA OF INTESTINE (WITHOUT HEMORRHAGE)

569.85 ANGIODYSPLASIA OF INTESTINE WITH HEMORRHAGE

569.86 DIEULAFOY LESION (HEMORRHAGIC) OF INTESTINE

569.87 VOMITING OF FECAL MATTER

569.89 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 FULL INCONTINENCE OF FECES

787.61 INCOMPLETE DEFECATION

787.62 FECAL SMEARING

787.63 FECAL URGENCY

787.91 DIARRHEA

787.99 OTHER SYMPTOMS INVOLVING DIGESTIVE SYSTEM

789.00 ABDOMINAL PAIN UNSPECIFIED SITE

789.01 ABDOMINAL PAIN RIGHT UPPER QUADRANT

789.02 ABDOMINAL PAIN LEFT UPPER QUADRANT

789.03 ABDOMINAL PAIN RIGHT LOWER QUADRANT

789.04 ABDOMINAL PAIN LEFT LOWER QUADRANT

789.05 ABDOMINAL PAIN PERIUMBILIC

789.06 ABDOMINAL PAIN EPIGASTRIC

789.07 ABDOMINAL PAIN GENERALIZED

789.09 ABDOMINAL PAIN OTHER SPECIFIED SITE

789.30 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE

789.31 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP RIGHT UPPER QUARDANT

789.32 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP LEFT UPPER QUADRANT

789.33 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP RIGHT LOWER QUADRANT

789.34 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP LEFT LOWER QUADRANT

789.35 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP PERIUMBILIC

789.36 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP EPIGASTRIC

789.37 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP GENERALIZED

789.39 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE

789.60 ABDOMINAL TENDERNESS UNSPECIFIED SITE

789.61 ABDOMINAL TENDERNESS RIGHT UPPER QUADRANT

789.62 ABDOMINAL TENDERNESS LEFT UPPER QUADRANT

789.63 ABDOMINAL TENDERNESS RIGHT LOWER QUADRANT

789.64 ABDOMINAL TENDERNESS LEFT LOWER QUADRANT

789.65 ABDOMINAL TENDERNESS PERIUMBILIC

789.66 ABDOMINAL TENDERNESS EPIGASTRIC

789.67 ABDOMINAL TENDERNESS GENERALIZED

789.69 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 FAMILY HISTORY, COLONIC POLYPS

V18.59 FAMILY HISTORY, OTHER DIGESTIVE DISORDERS

V76.50 SPECIAL SCREENING FOR MALIGNANT NEOPLASMS UNSPECIFIED INTESTINE

V76.51 SPECIAL SCREENING FOR MALIGNANT NEOPLASMS COLON

V76.52 SPECIAL SCREENING FOR MALIGNANT NEOPLASMS SMALL INTESTINE

 

 

Treatment Logic:

• 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.

 

 

Sources of Information and Basis for Decision

 

Practice Parameters Committee of the American College of Gastroenterology

 

The American Journal of Gastroenterology

 

FCSO LCD 29152, Diagnostic Colonoscopy, 10/01/2010. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

The New England Journal of Medicine

 

The U.S. Preventive Services Task Force, Washington, D.C.

 

 

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.

 

 

CMS LCD DIAGNOSTIC COLONOSCOPY