Diagnostic and Therapeutic Colonoscopy

Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A) states that no Medicare payment shall be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Title XVIII of the Social Security Act, §1862(a)(7) and 42 Code of Federal Regulations, §411.15 et seq. exclude routine physical examinations.

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

Title XVIII of the Social Security Act, §1862(a)(1)(H) and Balanced Budget Act ‘97’, Chapter V, Subtitle B, §4104 provides coverage for colorectal cancer screening tests.

CMS Manual System, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, §30.1B, addresses incomplete colonoscopies.

Colonoscopy is a visual examination of the lining of the large intestine using a rigid or flexible video or fiberoptic endoscope. The procedure includes inspection of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. A colonoscopy, by definition, must examine the colon proximal to the splenic flexure. The colonoscope is inserted via the anus or stoma, and then advanced under direct vision or video image. A rigid sigmoidoscope may be used for an intraoperative transcolotomy approach.

A colonoscopy requires the use of a flexible fiberoptic instrument that has the potential to examine the entire colon, and must potentially reach the entire colon (i.e. the cecum) when inserted through the anus.

Coverage for screening colonoscopy and other modalities for colorectal cancer is covered by CMS national policy NCD Chapter 1 Section 210.3 and in the Internet Only Manual 100-04, Chapter 18 Section 60.

A diagnostic colonoscopy is indicated for the following:

• Evaluation of an abnormality discovered by a radiology examination wherein the findings of the study are consistent with a colonic lesion that is likely to be clinically significant,
• An abnormal oncology colorectal screening or stool based DNA test as described in the CMS Colorectal Cancer screening Preventive Services requirements,
• Evaluation of unexplained gastrointestinal bleeding:
• Hematochezia that is not from the rectum or a perianal source,
• Melena of unknown origin after an upper GI source has been ruled out or when clinical findings indicate that a lower GI source may also be present,
• Presence of fecal occult blood, or
• Unexplained iron deficiency anemia.
• Clinically significant diarrhea of unexplained origin, after other appropriate workup,
• Evaluation of acute colonic ischemia/ischemic bowel disease,
• Evaluation of patients with streptococcus bovis endocarditis when a source is determined to likely to be of colonic origin (e.g. streptococcus bovis),
• Clinical suspicion of inflammatory bowel disease which may be manifested by abdominal pain, fever, diarrhea, bloody diarrhea, elevated erythrocyte sedimentation rate or other pertinent findings,
• Known chronic inflammatory bowel disease of the colon when a more precise determination of the extent of disease will influence clinical management,
• Surveillance of selected patients with Crohn’s colitis, or chronic ulcerative colitis for the purpose of ruling out colorectal cancer is considered high risk screening and should follow the requirements set forth in the CMS Internet Only Manual 100-04 Chapter 18 Section 60
• Surveillance of colonic neoplasia:
  • Evaluation of the entire colon for a cancer with polyps noted on an earlier colonoscopy in accordance with the established national guidelines.
  • This includes patients with known polyps from a previous colonoscopy or imaging study who have a known genetic predisposition for colon cancer.
• Intraoperative identification of the site of a lesion for findings that are suspected but that cannot be confirmed/detected by palpation or gross inspection at surgery.

Diagnostic colonoscopy is not covered for evaluation of the following:

• Chronic, stable irritable bowel syndrome,
• Acute limited diarrhea,
• Hemorrhoids,
• Metastatic adenocarcinoma of unknown primary site when a colonic origin is strongly suspected based on history and physical and imaging findings or biopsy reports,
• Routine follow-up of inflammatory bowel disease (except as indicated above in this section),
• Routine examination of the colon in patients about to undergo elective abdominal surgery for noncolonic disease,
• Upper GI bleeding or melena with a demonstrated upper GI source and absence of findings suggestive of a lower GI bleeding site,
• Bright red rectal bleeding in patients with a convincing anorectal source via direct examination, anoscopy, or sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source,
• Patients with a family history of colon cancer without a personal history of symptoms. These patients may be covered by the CMS Colorectal Screening coverage.

A therapeutic colonoscopy is indicated for:

• Treatment of bleeding from such lesions as vascular anomalies, ulceration, and neoplasia,
• Balloon dilation of a stenotic lesion,
• Decompression of a sigmoid volvulus and/or an acute non-toxic megacolon or pseudo-obstruction associated with Ogilvie’s Syndrome
• Removal of foreign body,
• Excision of colonic polyps.
• Repair of a perforation when it is expected that such repair will most likely avoid further surgical intervention and further surgical intervention is not needed (for example to drain an abscess at which time the perforation could be corrected by the surgeon)

Colonoscopy is contraindicated if the patient has:

• Fulminant colitis,
• Acute severe diverticulitis, or
• Suspected perforated viscus. A therapeutic colonoscopy by a trained endoscopist capable of repairing a perforation site may be allowed when the clinical findings and imaging studies strongly indicate that a perforation has occurred and the suspected site of the perforation allows for endoscopic repair.

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Documentation Requirement
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.

1. Medical Consultants
2. Anthem Guidelines for Colonoscopy (Accessed 08/10/2016): The role of endoscopy in the patient with lower GI bleeding; Gastrointestinal Endoscopy 2014 Vol. 79, No. 6, pp 875-885.
3. C42 CFR Ch IV Section 410.37
4. 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.
5. Colorectal Cancer Screening and Surveillance; American Family Physician January 15, 2015, pp 93-100.
6. Management of Crohn’s Disease in Adults American Journal of Gastroenterology Practice Guidelines January 6, 2009.
7. American Society for Gastrointestinal Endoscopy:
8. 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.
9. The role of endoscopy in inflammatory bowel disease; Gastrointestinal Endoscopy 2015 Vol. 81, No. 5, pp 1101-1121e13.
10. 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.
11. Other contractor’s local medical review policies.

NOTE: Some of the websites used to create this policy may no longer be available.

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• Diagnostic
• Therapeutic
• Colonoscopy