Local Coverage Determination (LCD)

Computed Tomographic (CT) Colonography for Diagnostic Uses

L33562

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33562
Original ICD-9 LCD ID
Not Applicable
LCD Title
Computed Tomographic (CT) Colonography for Diagnostic Uses
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 09/12/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. 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:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

42 CFR Section 410.38, subpart B indicates the tests approved for coverage of colorectal cancer screening

CMS Publications:

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1:

    220.1 Computed Tomography

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

    80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13:

    10 ICD-9-CM Coding for Diagnostic Tests
    20 Payment Conditions for Radiology Services
    80 Supervision and Interpretation (S & I) Codes and Interventional Radiology

 

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

CT colonography, utilizes helical computed tomography of the abdomen and pelvis to visualize the colon lumen, along with 3-D reconstruction. The test requires colonic preparation similar to that required for standard colonoscopy (instrument colonoscopy), and air insufflation to achieve colonic distention.

Indications:

CT colonography is indicated in those patients in whom a diagnostic (performed for signs/symptoms of disease) optical colonoscopy of the entire colon is incomplete. Failure to complete the optical colonoscopy may be secondary to conditions such as, but not limited to, an obstructing neoplasm, stricture, tortuosity, spasm, redundant colon diverticulitis, extrinsic compression or aberrant anatomy scarring from prior surgery.

CT colonography is indicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy or a physician with equivalent endoscopic training determines from an evaluation of the patient that optical colonoscopy cannot be safely attempted.

CT colonography is also indicated for the evaluation of a submucosal abnormality detected on colonoscopy or other imaging study.

CT colonography should be performed soon after the failed standard colonoscopy, if appropriate, so that the patient will not have to endure repeat colonic preparation.

Limitations:

CT colonography is not reimbursable when used in the absence of signs or symptoms of disease, regardless of family history or other risk factors for the development of colonic disease.

Since any colonography with abnormal or suspicious findings would require a subsequent instrument colonoscopy for diagnosis (e.g., biopsy) or for treatment (e.g., polypectomy), CT colonography is not reimbursable when used initially as an alternative to an instrument colonoscopy, even though performed for signs or symptoms of disease.

Irritable bowel syndrome and abdominal pain when representing chronic stable symptoms rarely represent reasonable indications for colonoscopy and CT colonography. These conditions have been placed on the list of covered diagnoses for use when a colonoscopy/colonography exam is normal in the face of compelling symptoms. When diagnosis codes representing these conditions are used, the codes must be applicable and the rationale for the colonoscopy/colonography must be carefully documented in the medical record.

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy). JAMA 291:1713-1719.

Dominitz JA, Eisen GM, Baron TH, et al. Complications of colonoscopy. Gastrointest Endosc.2003;57:1713-1719.

Fenlon, HM, McAneny DB, Nunes DP, Clarke PD, Ferrucci JT. Occlusive colon Carcinoma: virtual colonoscopy in the preoperative evaluation of the proximal colon. Radiology. 1999;210:423-428.

Johnson, CD, Harmsen WS, Wilson LA, et al. Prospective blinded evaluation of computed tomographic colonography for screen detection of colorectal polyps. Gastroenterology. 2003;125:311-319.

Laghi A, Iannaccone R, Carbone I, et al. Computed tomographic colonography (virtual colonoscopy): blinded prospective comparison with conventional colonoscopy for the detection of colorectal neoplasia. Endoscopy. 2002;34:441-446.

Laghi A, Iannaccone R, Carbone I, et al. Detection of colorectal lesions with virtual computed tomographic colonography. AM J Surg. 2002;183:124-131.

McCormick JT, Gregorcyk SG. Preoperative evaluation of colorectal cancer. Surg Oncol Clin N Am. 2006;15:39-49.

Morrin MM, Kruskal JB, Farrell RJ, Goldberg SN, McGee JB, Raptopoulos V. Endoluminal CT colonography after an incomplete endoscopic colonoscopy. AJR Am J Roentgenol. 1999;172:913-918.

Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349:2191-2200.

Ransohoff, DF. Virtual colonoscopy – what it can do vs what it will do. JAMA. 2004;291:1772-1774.

Other Medicare contractor policies consulted in development of the LCD:

  • AdminaStar Federal carrier LCD (Indiana [L22422], Kentucky [L22430])
  • AdminaStar Federal fiscal intermediary LCD (Illinois [L22058], Indiana [L22055], Kentucky [L22060], Ohio [L22062])
  • Associated Hospital Services fiscal intermediary LCDs [L19799/L19945])
  • Anthem Health Plans of New Hampshire fiscal intermediary LCD [L19942]
  • Empire Medicare Services carrier LCD (New Jersey [L16921], New York [L16894])
  • Empire Medicare Services fiscal intermediary LCD L17586
Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
09/12/2019 R6

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A57026. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
10/01/2018 R5

Due to the annual ICD-10-CM code update, ICD-10 codes K35.89 and K83.0 were deleted from "ICD-10-CM Codes that Support Medical Necessity" section - Group 2 and ICD-10 codes K35.890, K35.891, K83.01, and K83.09 were added as replacement codes.

DATE (10/01/2018): At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R4

Due to the annual ICD-10-CM code update, ICD-10-CM codes A04.7, K56.5 and K56.69 were deleted from Group 2 of the "ICD-10-CM Codes that Support Medical Necessity" section of the LCD. ICD-10-CM codes A04.71, A04.72, K56.50, K56.51, K56.690, K56.691 and K56.699 were added as the replacement codes. 

DATE (10/01/2017): At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R3 Due to the annual ICD-10-CM code update for 2017, ICD-10-CM codes K52.2, K55.0, K59.3 and K90.4 were deleted from Group 2 of the "ICD-10-CM Codes that Support Medical Necessity" section of the LCD. ICD-10-CM codes K59.31 and K59.39 were added as the replacement codes.

The descriptors were changed for ICD-10-CM codes T82.818A, T82.818D, T82.818S, T82.828A, T82.828D, T82.828S, T82.838A, T82.838D, T82.838S, T82.848A, T82.848D, T82.848S, T82.858A, T82.858D, T82.858S, T82.868A, T82.868D and T82.868S.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R2 Minor template language change.
  • Other
10/01/2015 R1 LCD title revised for clarity. Removed references to CPT code 74263 in the “Limitations” and “CPT/HCPCS Codes” sections on the basis screening services which are statutory exclusions should not be addressed in local coverage determinations (LCDs).

ICD-10-CM codes were added for the 7th character for D=subsequent encounter and S=sequela, where the 7th character, A=initial encounter, was already included.
  • Other
  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
09/06/2019 09/12/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • CT Colonography
  • Virtual Colonoscopy

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