L29167-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Diagnostic and Therapeutic

Esophagogastroduodenoscopy (L29167)

Contractor Information

Contractor Name

First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29167

LCD Title Diagnostic and Therapeutic Esophagogastroduodenoscopy

Contractor's Determination Number 43235

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 10/01/2011

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: CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter , Section 100.3

Indications and Limitations of Coverage and/or Medical Necessity

Upper intestinal endoscopy is performed with a lighted, flexible, fiberoptic instrument passed through the cricopharynx. The patient receives conscious sedation. A topical anesthetic is sometimes applied to the posterior pharynx. Direct visualization of the entire esophagus, stomach, and duodenum (to the junction of the second and third portions) can be accomplished easily with modern instruments that are less than 12mm in diameter. Esophagogastroduodenoscopy (EGD) is a technique utilized to examine, obtain samples, and in some instances, to treat pathological conditions.

Diagnostic observations are made concerning focal benign or malignant lesions, diffuse mucosal changes, luminal obstruction, motility, and extrinsic compression by contiguous structures. A diagnostic EGD allows the examiner to visualize abnormalities detectable by the technique and to photograph, biopsy, and/or remove lesions as appropriate.

The purpose of the therapeutic EGD is to manage hemorrhage; remove foreign bodies and neoplastic growths; to relieve obstruction due to stricture, malignancy, or other causes through dilatation or the placement of stents; and to assist in the placement of percutaneous gastrostomy tubes.

Medicare will consider EGD(s) to be medically reasonable and necessary under the following diagnostic conditions:

• Patient has upper abdominal distress (e.g., gastroesophageal reflux disease) which persists despite an appropriate trial of symptomatic therapy;

• Patient has upper abdominal distress associated with a short history of signs and symptoms suggesting significant associated disease or illness (e.g., weight loss, anorexia, vomiting, nonsteroidal anti-inflammatory drug NSAID intake, other gastric irritant intake);

• Patients over the age of 40 who have experienced a significant history of heartburn that returns after a course of symptomatic therapy;

• Patients who have dysphagia or odynophagia;

• Patient has persistent, unexplained vomiting;

• Patient has upper gastrointestinal x-ray findings of:

- any lesion that requires biopsy for diagnosis; or-

- gastric ulcer suspicious of cancer; or

- evidence of stricture or obstruction;

• To assess acute injury after caustic agent ingestion;

• When anti-reflux surgery is contemplated; or

• Patient has gastrointestinal bleeding:

- in most actively bleeding patients; or

- for presumed chronic blood loss and iron deficiency anemia when investigation of large bowel is negative. Medicare will consider EGD(s) to be medically reasonable and necessary for the following therapeutic purposes:

• Treatment of bleeding lesions;

• Removal of foreign bodies;

• Sclerotherapy and/or band ligation for bleeding from esophageal or gastric varices;

• Dilatation of strictures in the upper intestinal tract;

• Removal of selected polypoid lesions;

• Placement of feeding tubes; or

• Palliative therapy of stenosing neoplasms (e.g., laser, stent placement).

Gastrointestinal bleeding may be treated with a variety of methods. Direct contact heater probes and hemostatic injections into or around the bleeding vessels are both effective therapy for acute bleeding.

Foreign body removal from the stomach or esophagus is usually successful with these flexible instruments. The foreign bodies can be retrieved by either of two methods. The first method is to capture the foreign body with a snare device/grasping forceps and pull the item out with the endoscope. The second method is accomplished by piecemeal destruction and pushing the bolus through the esophagus into the stomach.

Esophageal varices may be injected with a variety of sclerosing solutions. Eradication of varices requires, on the average, five sclerotherapy sessions, with multiple injections given during each session.

Dilatation of strictures may be accomplished with a balloon placed through the endoscope and inflated using hydrostatic pressure. Bougies are rubber dilators available in various sizes up to approximately 2.0cm. Plastic bougies and other dilating probes are usually passed over a guide wire. This procedure involves placing the guide wire into the stomach through the endoscope. The endoscope is then withdrawn leaving the guide wire in place. The dilating probes and plastic bougies are then passed over the guide wire. After the largest dilator is used, the dilator and guide wire are removed. Esophageal dilation is performed after a definitive diagnosis has been established in patients exhibiting dysphagia. The goal in most cases is a lumenal diameter of 16-17mm which allows passage of solid food. A series of dilators may be passed over the guide wire to reach the goal of therapy.

Medicare will consider follow-up EGD(s) medically reasonable and necessary for the following indications:

• Biopsy surveillance of patients with Barrett’s esophagus every 12 to 24 months. However, if dysplasia is present, earlier surveillance intervals of from three to six months may be required;

• Follow-up of gastric ulcers to healing or satisfaction that they are benign;

• Follow-up and treatment of esophageal strictures requiring guidewire dilation;

• Follow-up of duodenal ulcer or other lesions of the upper gastrointestinal tract that have resulted in serious consequences (e.g., hemorrhage);

• Follow-up of patients having a previous gastric polypectomy for adenoma; or

• Follow-up and treatment of patients with esophageal varices or bleeding lesions requiring recurrent therapy (e.g., esophageal varices, gastric varices, angiodysplastic or watermelon stomach lesions, radiation gastritis).

• Follow-up for removal of percutaneous gastrostomy tube (PEG) Periodic EGD is NOT usually indicated in the following situations:

• Surveillance of healed, benign disease such as gastric or duodenal ulcer or benign esophageal strictures; or

• Cancer surveillance in patients with pernicious anemia, treated achalasia, or prior gastric resection. EGD is generally contraindicated for patients with recent myocardial infarction.

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

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43235 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF

SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43236 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY

SUBSTANCE

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43237 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION

LIMITED TO THE ESOPHAGUS

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43238 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED

INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), ESOPHAGUS (INCLUDES

ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS)

43239 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BIOPSY, SINGLE OR MULTIPLE

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43241 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC INTRALUMINAL TUBE OR

CATHETER PLACEMENT

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE

43243 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL AND/OR GASTRIC VARICES

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43244 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BAND LIGATION OF ESOPHAGEAL AND/OR

GASTRIC VARICES

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43245 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DILATION OF GASTRIC OUTLET FOR

OBSTRUCTION (EG, BALLOON, GUIDE WIRE, BOUGIE)

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43246 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DIRECTED PLACEMENT OF PERCUTANEOUS

GASTROSTOMY TUBE

43247 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF FOREIGN BODY

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE 43248 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY

DILATION OF ESOPHAGUS OVER GUIDE WIRE

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE

43249 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BALLOON DILATION OF ESOPHAGUS (LESS THAN

30 MM DIAMETER)

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE

43250 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE

43251 DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE

43255 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH CONTROL OF BLEEDING, ANY METHOD

43258

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE

ICD-9 Codes that Support Medical Necessity

040.2 WHIPPLE'S DISEASE

112.84 CANDIDAL ESOPHAGITIS

150.0 - 152.9

MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

156.0 - 156.9

157.0 - 157.9

MALIGNANT NEOPLASM OF GALLBLADDER - MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE

MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

159.8 MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE SYSTEM AND INTRA-ABDOMINAL ORGANS

176.3 KAPOSI'S SARCOMA GASTROINTESTINAL SITES

197.4 SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE INCLUDING DUODENUM

197.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM

198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE

211.0 - 211.9

BENIGN NEOPLASM OF ESOPHAGUS - BENIGN NEOPLASM OF OTHER AND UNSPECIFIED SITE IN THE DIGESTIVE SYSTEM

214.3 LIPOMA OF INTRA-ABDOMINAL ORGANS

214.9 LIPOMA UNSPECIFIED SITE

215.9 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED

228.04 HEMANGIOMA OF INTRA-ABDOMINAL STRUCTURES

230.1 - 230.8

235.2 - 235.4

CARCINOMA IN SITU OF ESOPHAGUS - CARCINOMA IN SITU OF LIVER AND BILIARY SYSTEM

NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM - NEOPLASM OF UNCERTAIN BEHAVIOR OF RETROPERITONEUM AND PERITONEUM

239.0 NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM

251.5 ABNORMALITY OF SECRETION OF GASTRIN

261 NUTRITIONAL MARASMUS

263.0 - 263.9 MALNUTRITION OF MODERATE DEGREE - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

280.0 - 280.9

IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC) - IRON DEFICIENCY ANEMIA UNSPECIFIED

285.1 ACUTE POSTHEMORRHAGIC ANEMIA

300.11 CONVERSION DISORDER

306.4 GASTROINTESTINAL MALFUNCTION ARISING FROM MENTAL FACTORS

307.1 ANOREXIA NERVOSA

307.50 EATING DISORDER UNSPECIFIED

307.51 BULIMIA NERVOSA

307.52 PICA

307.53 RUMINATION DISORDER

307.54 PSYCHOGENIC VOMITING

438.82 DYSPHAGIA CEREBROVASCULAR DISEASE

447.2 RUPTURE OF ARTERY

448.0 HEREDITARY HEMORRHAGIC TELANGIECTASIA

456.1 ESOPHAGEAL VARICES WITH BLEEDING

456.2 ESOPHAGEAL VARICES WITHOUT BLEEDING

456.20 - 456.21

ESOPHAGEAL VARICES IN DISEASES CLASSIFIED ELSEWHERE WITH BLEEDING - ESOPHAGEAL VARICES IN DISEASES CLASSIFIED ELSEWHERE WITHOUT BLEEDING

507.0 PNEUMONITIS DUE TO INHALATION OF FOOD OR VOMITUS

530.0 - 530.89 ACHALASIA AND CARDIOSPASM - OTHER DISEASES OF ESOPHAGUS

531.00 - 531.91

532.00 - 532.91

533.00 - 533.91

534.00 - 534.91

535.00 - 535.71

ACUTE GASTRIC ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - GASTRIC ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION

ACUTE DUODENAL ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - DUODENAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION

ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE WITHOUT OBSTRUCTION - PEPTIC ULCER OF UNSPECIFIED SITE UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION

ACUTE GASTROJEJUNAL ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - GASTROJEJUNAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION

ACUTE GASTRITIS (WITHOUT HEMORRHAGE) - EOSINOPHILIC GASTRITIS, WITH HEMORRHAGE

536.1 ACUTE DILATATION OF STOMACH

536.2 PERSISTENT VOMITING

536.3 GASTROPARESIS

536.40 - 536.49

GASTROSTOMY COMPLICATION UNSPECIFIED - OTHER GASTROSTOMY COMPLICATIONS

536.8 DYSPEPSIA AND OTHER SPECIFIED DISORDERS OF FUNCTION OF STOMACH

537.0 - 537.89 ACQUIRED HYPERTROPHIC PYLORIC STENOSIS - OTHER SPECIFIED DISORDERS OF STOMACH AND DUODENUM

538 GASTROINTESTINAL MUCOSITIS (ULCERATIVE)

551.3 DIAPHRAGMATIC HERNIA WITH GANGRENE

552.3 - 552.8

DIAPHRAGMATIC HERNIA WITH OBSTRUCTION - HERNIA OF OTHER SPECIFIED SITES WITH OBSTRUCTION

553.3 DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE

555.0 - 555.9 REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE

560.9 UNSPECIFIED INTESTINAL OBSTRUCTION

562.1 DIVERTICULITIS OF SMALL INTESTINE (WITHOUT HEMORRHAGE)

562.2 DIVERTICULOSIS OF SMALL INTESTINE WITH HEMORRHAGE

562.3 DIVERTICULITIS OF SMALL INTESTINE WITH HEMORRHAGE

569.62 MECHANICAL COMPLICATION OF COLOSTOMY AND ENTEROSTOMY

569.71 - 569.79 POUCHITIS - OTHER COMPLICATIONS OF INTESTINAL POUCH

569.82 ULCERATION OF INTESTINE

569.87 VOMITING OF FECAL MATTER

571.1 ACUTE ALCOHOLIC HEPATITIS

571.2 ALCOHOLIC CIRRHOSIS OF LIVER

571.3 ALCOHOLIC LIVER DAMAGE UNSPECIFIED

571.40 CHRONIC HEPATITIS UNSPECIFIED

571.41 CHRONIC PERSISTENT HEPATITIS

571.42 AUTOIMMUNE HEPATITIS

571.49 OTHER CHRONIC HEPATITIS

571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL

571.6 BILIARY CIRRHOSIS

572.3 PORTAL HYPERTENSION

574.1 - 574.2

574.10 - 574.11

574.20 - 574.21

CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS WITHOUT OBSTRUCTION - CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS WITH OBSTRUCTION

CALCULUS OF GALLBLADDER WITH OTHER CHOLECYSTITIS WITHOUT OBSTRUCTION - CALCULUS OF GALLBLADDER WITH OTHER CHOLECYSTITIS WITH OBSTRUCTION

CALCULUS OF GALLBLADDER WITHOUT CHOLECYSTITIS WITHOUT OBSTRUCTION - CALCULUS OF GALLBLADDER WITHOUT CHOLECYSTITIS WITH OBSTRUCTION

CALCULUS OF BILE DUCT WITH ACUTE CHOLECYSTITIS WITHOUT OBSTRUCTION - CALCULUS OF BILE DUCT WITH ACUTE CHOLECYSTITIS WITH OBSTRUCTION

574.30 - 574.31

574.40 - 574.41

CALCULUS OF BILE DUCT WITH OTHER CHOLECYSTITIS WITHOUT OBSTRUCTION - CALCULUS OF BILE DUCT WITH OTHER CHOLECYSTITIS WITH OBSTRUCTION

575.0 ACUTE CHOLECYSTITIS

575.5 FISTULA OF GALLBLADDER

576.0 POSTCHOLECYSTECTOMY SYNDROME

576.4 FISTULA OF BILE DUCT

577.1 ACUTE PANCREATITIS

577.2 CHRONIC PANCREATITIS

577.3 CYST AND PSEUDOCYST OF PANCREAS

578.0 - 578.9 HEMATEMESIS - HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED

579.0 - 579.9 CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION

694.0 DERMATITIS HERPETIFORMIS

710.1 SYSTEMIC SCLEROSIS

747.61 GASTROINTESTINAL VESSEL ANOMALY

750.3 CONGENITAL TRACHEOESOPHAGEAL FISTULA ESOPHAGEAL ATRESIA AND STENOSIS

750.4 OTHER SPECIFIED CONGENITAL ANOMALIES OF ESOPHAGUS

750.5 CONGENITAL HYPERTROPHIC PYLORIC STENOSIS

750.6 CONGENITAL HIATUS HERNIA

750.7 OTHER SPECIFIED CONGENITAL ANOMALIES OF STOMACH

783.0 ANOREXIA

783.21 - 783.3 opens

in new window LOSS OF WEIGHT - FEEDING DIFFICULTIES AND MISMANAGEMENT

784.42 DYSPHONIA

784.43 HYPERNASALITY

784.44 HYPONASALITY

784.49 OTHER VOICE AND RESONANCE DISORDERS

784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE

784.91 - 784.99

POSTNASAL DRIP - OTHER SYMPTOMS INVOLVING HEAD AND NECK

786.2 COUGH

786.50 - 786.59

UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN

786.6 SWELLING MASS OR LUMP IN CHEST

787.01 - 787.91

789.00 - 789.09

789.39

789.51 -789.59

789.60 - 789.69 opens in new window

NAUSEA WITH VOMITING - DIARRHEA

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

PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE

MALIGNANT ASCITES - OTHER ASCITES

ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL TENDERNESS OTHER SPECIFIED SITE

790.5 OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS

790.99 OTHER ABNORMAL FINDINGS ON EXAMINATION OF BLOOD

792.1 NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS

793.4 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT

793.6

NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM

799.4 CACHEXIA

862.22 INJURY TO ESOPHAGUS WITHOUT OPEN WOUND INTO CAVITY

874.4 - 874.5 opens in new window 935.1 - 935.2 opens

OPEN WOUND OF PHARYNX WITHOUT COMPLICATION - OPEN WOUND OF PHARYNX COMPLICATED

in new window FOREIGN BODY IN ESOPHAGUS - FOREIGN BODY IN STOMACH

936 FOREIGN BODY IN INTESTINE AND COLON

938 FOREIGN BODY IN DIGESTIVE SYSTEM UNSPECIFIED

947.0 BURN OF MOUTH AND PHARYNX

947.2 - 947.3 opens

in new window BURN OF ESOPHAGUS - BURN OF GASTROINTESTINAL TRACT

959.01 -

959.09 opens in new window

983.2 - 983.9 opens

OTHER AND UNSPECIFIED INJURY TO HEAD - OTHER AND UNSPECIFIED INJURY TO FACE AND NECK

in new window TOXIC EFFECT OF CAUSTIC ALKALIS - TOXIC EFFECT OF CAUSTIC UNSPECIFIED

990 EFFECTS OF RADIATION UNSPECIFIED

996.82 COMPLICATIONS OF TRANSPLANTED LIVER

997.41 -

997.49 opens in new window

RETAINED CHOLELITHIASIS FOLLOWING CHOLECYSTECTOMY - OTHER DIGESTIVE SYSTEM COMPLICATIONS

E864.1* ACCIDENTAL POISONING BY ACIDS NOT ELSEWHERE CLASSIFIED

E864.2* ACCIDENTAL POISONING BY CAUSTIC ALKALIS NOT ELSEWHERE CLASSIFIED

E864.3* ACCIDENTAL POISONING BY OTHER SPECIFIED CORROSIVES AND CAUSTICS NOT ELSEWHERE CLASSIFIED

E864.4* ACCIDENTAL POISONING BY UNSPECIFIED CORROSIVES AND CAUSTICS NOT ELSEWHERE CLASSIFIED

E961* ASSAULT BY CORROSIVE OR CAUSTIC SUBSTANCE EXCEPT POISONING

V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN GASTROINTESTINAL TRACT

V10.03 -

V10.04 opens in new window

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF STOMACH

V10.09 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN GASTROINTESTINAL TRACT

V12.71 PERSONAL HISTORY OF PEPTIC ULCER DISEASE

V12.72 PERSONAL HISTORY OF COLONIC POLYPS

V12.79 PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM DISEASES

V18.51 -

V18.59 opens in new window

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

V55.1 ATTENTION TO GASTROSTOMY

V58.61 LONG-TERM (CURRENT) USE OF ANTICOAGULANTS

V58.64 LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTI-INFLAMMATORIES V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V69.1 INAPPROPRIATE DIET AND EATING HABITS

* According to the ICD-9-CM book, diagnosis codes E864.1, E864.2, E864.3, E864.4 and E961 are secondary diagnosis codes and should not be billed as the primary diagnosis.

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

Printed on 9/29/2012. Page 8 of 11

General Information

Documentations Requirements

The patient’s medical record (e.g., history and physical, office/progress notes, procedure report) maintained by the ordering/referring physician must clearly indicate the reason for the EGD. Also, the results of the EGD must

be included in the patient’s medical record.

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.

The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1

(http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) outlines that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or 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.This service will be considered medically reasonable and necessary only if performed by providers of gastroenterology services, or other providers who have specialized training and expertise in performing the

procedure in question.

Sources of Information and Basis for Decision

American Society of Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. Gastrointestinal Endoscopy, 52(6) 831-7.

Cappell, M.S., & Friedel, D. (2002). The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders. The Medical Clinics of North America 86(6) pg 1165-1216.

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 the 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 4

Revision History Explanation Revision Number:4 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011

Revised Effective Date 10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Deleted diagnosis code 997.4. Added new diagnosis code range 997.41-997.49. The effective date of this revision is based on date of service.

Revision Number:3

Start Date of Comment Period:N/A

Start Date of Notice Period:07/01/2011 Revised Effective Date 06/14/2011

LCR B2011-072

June 2011 Connection

Explanation of Revision: Based on an outside request to clarify our current training statement outlined in this LCD, language under the “Utilization Guidelines” section of the LCD has been deleted and replaced with a revised statement regarding the qualification and training. Revisions will be effective based on process date.

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 Revisions: Annual 2011 ICD-9-CM Update. Added diagnosis code 784.52 and descriptor. 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 Revisions: Annual 2010 ICD-9-CM Update. Added diagnosis codes 569.71-569.79, 569.87, 784.42, 784.43, and 784.44. Revised descriptors for diagnosis codes 784.49, 793.4 and 793.6. 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 (L29167) replaces LCD L6275 as the policy in notice. This document (L29167) 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:

43235 descriptor was changed in Group 1 43237 descriptor was changed in Group 1 43239 descriptor was changed in Group 1 43249 descriptor was changed in Group 1

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change