Supportive clinical documentation evidencing the condition and treatment is expected to be documented in the clinical notes or procedure note and be made available upon request from the MAC or other authorized CMS auditor.
Medical records need not be submitted with the claim, unless the procedure was more complex than expected. However, they must be furnished to Medicare upon request.
The medical records must support the medical reasonableness, necessity, and frequency of each diagnostic service supplied.
The medical record must substantiate the diagnosis listed on the claim form.
The colonoscopy report must describe the following:
- The maximum depth of penetration;
- A description of any abnormal findings; and
- Any procedures performed as the result of such findings (e.g., biopsy).
For a colonoscopy performed in the office, the provider shall maintain on file the make, model number, and serial number of the colonoscope and provide this information to the contractor upon request.
The patient’s medical record must be legible and clearly indicate the medical need for the colonoscopy. In addition, the medical record must include the test result and document its impact on treatment.
If the only indication is abdominal pain, the documentation must show the chronic nature of the pain, the medical therapy tried, and the response.
Typically, the initial follow-up for colorectal cancer, adenomatous or neoplastic polyps is a colonoscopy in 1 year, then 3-5 year intervals following resection.
- Medical Consultants
- Anthem Guidelines for Colonoscopy
- The role of endoscopy in the patient with lower GI bleeding; Gastrointestinal Endoscopy 2014 Vol. 79, No. 6, pp 875-885.
- C42 CFR Ch IV Section 410.37
- Colonoscopy surveillance after colorectal cancer resection: recommendations of the US multi-society task force on colorectal cancer; Gastrointestinal Endoscopy 2016 Vol.83, No. 3, pp 489-498e10.
- Colorectal Cancer Screening and Surveillance; American Family Physician January 15, 2015, pp 93-100.
- Management of Crohn’s Disease in Adults American Journal of Gastroenterology Practice Guidelines January 6, 2009.
- American Society for Gastrointestinal Endoscopy:
- Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer GASTROENTEROLOGY 2012;143:844–857.
- The role of endoscopy in inflammatory bowel disease; Gastrointestinal Endoscopy 2015 Vol. 81, No. 5, pp 1101-1121e13.
- The role of endoscopy in the management of patients with known or suspected colonic obstruction or pseudo-obstruction; Gastrointestinal Endoscopy 2010 Vol. 71, No.4, pp 669-679.
- Other contractor’s local medical review policies.
NOTE: Some of the websites used to create this policy may no longer be available.