LCD Reference Article Billing and Coding Article

Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

A57414

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
N/A
Article ID
A57414
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
Article Type
Billing and Coding
Original Effective Date
10/01/2019
Revision Effective Date
10/01/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35350, Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

  1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(455 Codes)
Group 1 Paragraph

It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Note: Not all covered ICD-10-CM codes apply to each CPT procedure and only the appropriate one will be covered.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 43200, 43201, 43202, 43204, 43205, 43206, 43212, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43231, 43232, 43235, 43236, 43237, 43238, 43239, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43255, 43257, 43259, 43260, 43261, 43262, 43263, 43264, 43265, 43266, 43270, 43274, 43275, 43276, 43277, and 43278.

Group 1 Codes
Code Description
B37.81 Candidal esophagitis
C15.3 Malignant neoplasm of upper third of esophagus
C15.4 Malignant neoplasm of middle third of esophagus
C15.5 Malignant neoplasm of lower third of esophagus
C15.8 Malignant neoplasm of overlapping sites of esophagus
C15.9 Malignant neoplasm of esophagus, unspecified
C16.0 Malignant neoplasm of cardia
C16.1 Malignant neoplasm of fundus of stomach
C16.2 Malignant neoplasm of body of stomach
C16.3 Malignant neoplasm of pyloric antrum
C16.4 Malignant neoplasm of pylorus
C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified
C16.6 Malignant neoplasm of greater curvature of stomach, unspecified
C16.8 Malignant neoplasm of overlapping sites of stomach
C16.9 Malignant neoplasm of stomach, unspecified
C17.0 Malignant neoplasm of duodenum
C25.0 Malignant neoplasm of head of pancreas
C25.1 Malignant neoplasm of body of pancreas
C25.2 Malignant neoplasm of tail of pancreas
C25.3 Malignant neoplasm of pancreatic duct
C25.4 Malignant neoplasm of endocrine pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
C49.A1 Gastrointestinal stromal tumor of esophagus
C49.A2 Gastrointestinal stromal tumor of stomach
C49.A3 Gastrointestinal stromal tumor of small intestine
C7A.092 Malignant carcinoid tumor of the stomach
C78.4 Secondary malignant neoplasm of small intestine
C88.40 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] not having achieved remission
D00.1 Carcinoma in situ of esophagus
D00.2 Carcinoma in situ of stomach
D01.7 Carcinoma in situ of other specified digestive organs
D01.9 Carcinoma in situ of digestive organ, unspecified
D13.0 Benign neoplasm of esophagus
D13.1 Benign neoplasm of stomach
D13.2 Benign neoplasm of duodenum
D13.30 Benign neoplasm of unspecified part of small intestine
D13.39 Benign neoplasm of other parts of small intestine
D37.1 Neoplasm of uncertain behavior of stomach
D37.2 Neoplasm of uncertain behavior of small intestine
D37.3 Neoplasm of uncertain behavior of appendix
D37.4 Neoplasm of uncertain behavior of colon
D37.5 Neoplasm of uncertain behavior of rectum
D37.6 Neoplasm of uncertain behavior of liver, gallbladder and bile ducts
D49.0 Neoplasm of unspecified behavior of digestive system
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D50.9 Iron deficiency anemia, unspecified
D62 Acute posthemorrhagic anemia
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
E41 Nutritional marasmus
E43* Unspecified severe protein-calorie malnutrition
E44.0 Moderate protein-calorie malnutrition
E46 Unspecified protein-calorie malnutrition
E64.0 Sequelae of protein-calorie malnutrition
I69.091 Dysphagia following nontraumatic subarachnoid hemorrhage
I69.191 Dysphagia following nontraumatic intracerebral hemorrhage
I69.291 Dysphagia following other nontraumatic intracranial hemorrhage
I69.391 Dysphagia following cerebral infarction
I69.891 Dysphagia following other cerebrovascular disease
I69.991 Dysphagia following unspecified cerebrovascular disease
I77.2 Rupture of artery
I85.00 Esophageal varices without bleeding
I85.01 Esophageal varices with bleeding
I85.10 Secondary esophageal varices without bleeding
I85.11 Secondary esophageal varices with bleeding
I86.4 Gastric varices
J86.0 Pyothorax with fistula
K20.0 Eosinophilic esophagitis
K20.80 Other esophagitis without bleeding
K20.81 Other esophagitis with bleeding
K20.90 Esophagitis, unspecified without bleeding
K20.91 Esophagitis, unspecified with bleeding
K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding
K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding
K21.9 Gastro-esophageal reflux disease without esophagitis
K22.0 Achalasia of cardia
K22.10 Ulcer of esophagus without bleeding
K22.11 Ulcer of esophagus with bleeding
K22.2 Esophageal obstruction
K22.3 Perforation of esophagus
K22.4 Dyskinesia of esophagus
K22.5 Diverticulum of esophagus, acquired
K22.6 Gastro-esophageal laceration-hemorrhage syndrome
K22.70 Barrett's esophagus without dysplasia
K22.710 Barrett's esophagus with low grade dysplasia
K22.711 Barrett's esophagus with high grade dysplasia
K22.719 Barrett's esophagus with dysplasia, unspecified
K22.81 Esophageal polyp
K22.82 Esophagogastric junction polyp
K22.89 Other specified disease of esophagus
K25.0 Acute gastric ulcer with hemorrhage
K25.1 Acute gastric ulcer with perforation
K25.2 Acute gastric ulcer with both hemorrhage and perforation
K25.3 Acute gastric ulcer without hemorrhage or perforation
K25.4 Chronic or unspecified gastric ulcer with hemorrhage
K25.5 Chronic or unspecified gastric ulcer with perforation
K25.6 Chronic or unspecified gastric ulcer with both hemorrhage and perforation
K25.7 Chronic gastric ulcer without hemorrhage or perforation
K25.9 Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation
K26.0 Acute duodenal ulcer with hemorrhage
K26.1 Acute duodenal ulcer with perforation
K26.2 Acute duodenal ulcer with both hemorrhage and perforation
K26.3 Acute duodenal ulcer without hemorrhage or perforation
K26.4 Chronic or unspecified duodenal ulcer with hemorrhage
K26.5 Chronic or unspecified duodenal ulcer with perforation
K26.6 Chronic or unspecified duodenal ulcer with both hemorrhage and perforation
K26.7 Chronic duodenal ulcer without hemorrhage or perforation
K26.9 Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
K27.0 Acute peptic ulcer, site unspecified, with hemorrhage
K27.1 Acute peptic ulcer, site unspecified, with perforation
K27.2 Acute peptic ulcer, site unspecified, with both hemorrhage and perforation
K27.3 Acute peptic ulcer, site unspecified, without hemorrhage or perforation
K27.4 Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage
K27.5 Chronic or unspecified peptic ulcer, site unspecified, with perforation
K27.6 Chronic or unspecified peptic ulcer, site unspecified, with both hemorrhage and perforation
K27.7 Chronic peptic ulcer, site unspecified, without hemorrhage or perforation
K27.9 Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation
K28.0 Acute gastrojejunal ulcer with hemorrhage
K28.1 Acute gastrojejunal ulcer with perforation
K28.2 Acute gastrojejunal ulcer with both hemorrhage and perforation
K28.3 Acute gastrojejunal ulcer without hemorrhage or perforation
K28.4 Chronic or unspecified gastrojejunal ulcer with hemorrhage
K28.5 Chronic or unspecified gastrojejunal ulcer with perforation
K28.6 Chronic or unspecified gastrojejunal ulcer with both hemorrhage and perforation
K28.7 Chronic gastrojejunal ulcer without hemorrhage or perforation
K28.9 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
K29.00 Acute gastritis without bleeding
K29.01 Acute gastritis with bleeding
K29.20 Alcoholic gastritis without bleeding
K29.21 Alcoholic gastritis with bleeding
K29.30 Chronic superficial gastritis without bleeding
K29.31 Chronic superficial gastritis with bleeding
K29.40 Chronic atrophic gastritis without bleeding
K29.41 Chronic atrophic gastritis with bleeding
K29.50 Unspecified chronic gastritis without bleeding
K29.51 Unspecified chronic gastritis with bleeding
K29.60 Other gastritis without bleeding
K29.61 Other gastritis with bleeding
K29.70 Gastritis, unspecified, without bleeding
K29.71 Gastritis, unspecified, with bleeding
K29.80 Duodenitis without bleeding
K29.81 Duodenitis with bleeding
K29.90 Gastroduodenitis, unspecified, without bleeding
K29.91 Gastroduodenitis, unspecified, with bleeding
K31.1 Adult hypertrophic pyloric stenosis
K31.2 Hourglass stricture and stenosis of stomach
K31.3 Pylorospasm, not elsewhere classified
K31.4 Gastric diverticulum
K31.5 Obstruction of duodenum
K31.6 Fistula of stomach and duodenum
K31.7 Polyp of stomach and duodenum
K31.811 Angiodysplasia of stomach and duodenum with bleeding
K31.819 Angiodysplasia of stomach and duodenum without bleeding
K31.82 Dieulafoy lesion (hemorrhagic) of stomach and duodenum
K31.84 Gastroparesis
K31.89 Other diseases of stomach and duodenum
K31.A11 Gastric intestinal metaplasia without dysplasia, involving the antrum
K31.A12 Gastric intestinal metaplasia without dysplasia, involving the body (corpus)
K31.A13 Gastric intestinal metaplasia without dysplasia, involving the fundus
K31.A14 Gastric intestinal metaplasia without dysplasia, involving the cardia
K31.A15 Gastric intestinal metaplasia without dysplasia, involving multiple sites
K31.A19 Gastric intestinal metaplasia without dysplasia, unspecified site
K31.A21 Gastric intestinal metaplasia with low grade dysplasia
K31.A22 Gastric intestinal metaplasia with high grade dysplasia
K44.0 Diaphragmatic hernia with obstruction, without gangrene
K52.81 Eosinophilic gastritis or gastroenteritis
K70.30 Alcoholic cirrhosis of liver without ascites
K70.31 Alcoholic cirrhosis of liver with ascites
K71.7 Toxic liver disease with fibrosis and cirrhosis of liver
K74.3 Primary biliary cirrhosis
K74.4 Secondary biliary cirrhosis
K74.5 Biliary cirrhosis, unspecified
K74.60 Unspecified cirrhosis of liver
K74.69 Other cirrhosis of liver
K76.6 Portal hypertension
K80.00 Calculus of gallbladder with acute cholecystitis without obstruction
K80.01 Calculus of gallbladder with acute cholecystitis with obstruction
K80.10 Calculus of gallbladder with chronic cholecystitis without obstruction
K80.11 Calculus of gallbladder with chronic cholecystitis with obstruction
K80.12 Calculus of gallbladder with acute and chronic cholecystitis without obstruction
K80.13 Calculus of gallbladder with acute and chronic cholecystitis with obstruction
K80.18 Calculus of gallbladder with other cholecystitis without obstruction
K80.19 Calculus of gallbladder with other cholecystitis with obstruction
K80.20 Calculus of gallbladder without cholecystitis without obstruction
K80.21 Calculus of gallbladder without cholecystitis with obstruction
K80.30 Calculus of bile duct with cholangitis, unspecified, without obstruction
K80.31 Calculus of bile duct with cholangitis, unspecified, with obstruction
K80.32 Calculus of bile duct with acute cholangitis without obstruction
K80.33 Calculus of bile duct with acute cholangitis with obstruction
K80.34 Calculus of bile duct with chronic cholangitis without obstruction
K80.35 Calculus of bile duct with chronic cholangitis with obstruction
K80.36 Calculus of bile duct with acute and chronic cholangitis without obstruction
K80.37 Calculus of bile duct with acute and chronic cholangitis with obstruction
K80.40 Calculus of bile duct with cholecystitis, unspecified, without obstruction
K80.41 Calculus of bile duct with cholecystitis, unspecified, with obstruction
K80.42 Calculus of bile duct with acute cholecystitis without obstruction
K80.43 Calculus of bile duct with acute cholecystitis with obstruction
K80.44 Calculus of bile duct with chronic cholecystitis without obstruction
K80.45 Calculus of bile duct with chronic cholecystitis with obstruction
K80.46 Calculus of bile duct with acute and chronic cholecystitis without obstruction
K80.47 Calculus of bile duct with acute and chronic cholecystitis with obstruction
K80.50 Calculus of bile duct without cholangitis or cholecystitis without obstruction
K80.51 Calculus of bile duct without cholangitis or cholecystitis with obstruction
K80.60 Calculus of gallbladder and bile duct with cholecystitis, unspecified, without obstruction
K80.61 Calculus of gallbladder and bile duct with cholecystitis, unspecified, with obstruction
K80.62 Calculus of gallbladder and bile duct with acute cholecystitis without obstruction
K80.63 Calculus of gallbladder and bile duct with acute cholecystitis with obstruction
K80.64 Calculus of gallbladder and bile duct with chronic cholecystitis without obstruction
K80.65 Calculus of gallbladder and bile duct with chronic cholecystitis with obstruction
K80.66 Calculus of gallbladder and bile duct with acute and chronic cholecystitis without obstruction
K80.67 Calculus of gallbladder and bile duct with acute and chronic cholecystitis with obstruction
K80.70 Calculus of gallbladder and bile duct without cholecystitis without obstruction
K80.71 Calculus of gallbladder and bile duct without cholecystitis with obstruction
K80.80 Other cholelithiasis without obstruction
K80.81 Other cholelithiasis with obstruction
K83.01 Primary sclerosing cholangitis
K83.09 Other cholangitis
K83.1 Obstruction of bile duct
K83.2 Perforation of bile duct
K83.3 Fistula of bile duct
K83.4 Spasm of sphincter of Oddi
K83.5 Biliary cyst
K83.8 Other specified diseases of biliary tract
K83.9 Disease of biliary tract, unspecified
K85.00 Idiopathic acute pancreatitis without necrosis or infection
K85.01 Idiopathic acute pancreatitis with uninfected necrosis
K85.02 Idiopathic acute pancreatitis with infected necrosis
K85.10 Biliary acute pancreatitis without necrosis or infection
K85.11 Biliary acute pancreatitis with uninfected necrosis
K85.12 Biliary acute pancreatitis with infected necrosis
K85.20 Alcohol induced acute pancreatitis without necrosis or infection
K85.21 Alcohol induced acute pancreatitis with uninfected necrosis
K85.22 Alcohol induced acute pancreatitis with infected necrosis
K85.30 Drug induced acute pancreatitis without necrosis or infection
K85.31 Drug induced acute pancreatitis with uninfected necrosis
K85.32 Drug induced acute pancreatitis with infected necrosis
K85.80 Other acute pancreatitis without necrosis or infection
K85.81 Other acute pancreatitis with uninfected necrosis
K85.82 Other acute pancreatitis with infected necrosis
K85.90 Acute pancreatitis without necrosis or infection, unspecified
K85.91 Acute pancreatitis with uninfected necrosis, unspecified
K85.92 Acute pancreatitis with infected necrosis, unspecified
K86.0 Alcohol-induced chronic pancreatitis
K86.1 Other chronic pancreatitis
K86.2 Cyst of pancreas
K86.3 Pseudocyst of pancreas
K86.81 Exocrine pancreatic insufficiency
K86.89 Other specified diseases of pancreas
K87 Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere
K91.30 Postprocedural intestinal obstruction, unspecified as to partial versus complete
K91.31 Postprocedural partial intestinal obstruction
K91.32 Postprocedural complete intestinal obstruction
K91.5 Postcholecystectomy syndrome
K91.81 Other intraoperative complications of digestive system
K91.82 Postprocedural hepatic failure
K91.83 Postprocedural hepatorenal syndrome
K91.86 Retained cholelithiasis following cholecystectomy
K91.89 Other postprocedural complications and disorders of digestive system
K92.0 Hematemesis
K92.1 Melena
K92.2 Gastrointestinal hemorrhage, unspecified
K92.81 Gastrointestinal mucositis (ulcerative)
K94.23 Gastrostomy malfunction
K94.30 Esophagostomy complications, unspecified
K94.31 Esophagostomy hemorrhage
K94.32 Esophagostomy infection
K94.33 Esophagostomy malfunction
K94.39 Other complications of esophagostomy
Q26.5 Anomalous portal venous connection
Q26.6 Portal vein-hepatic artery fistula
Q27.33 Arteriovenous malformation of digestive system vessel
Q39.0 Atresia of esophagus without fistula
Q39.1 Atresia of esophagus with tracheo-esophageal fistula
Q39.2 Congenital tracheo-esophageal fistula without atresia
Q39.3 Congenital stenosis and stricture of esophagus
Q39.4 Esophageal web
Q39.5 Congenital dilatation of esophagus
Q39.6 Congenital diverticulum of esophagus
Q39.8 Other congenital malformations of esophagus
Q39.9 Congenital malformation of esophagus, unspecified
Q40.2 Other specified congenital malformations of stomach
Q40.3 Congenital malformation of stomach, unspecified
R07.9 Chest pain, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.33 Periumbilical pain
R11.0 Nausea
R11.10 Vomiting, unspecified
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.15 Cyclical vomiting syndrome unrelated to migraine
R11.2 Nausea with vomiting, unspecified
R12 Heartburn
R13.0 Aphagia
R13.10 Dysphagia, unspecified
R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase
R13.13 Dysphagia, pharyngeal phase
R13.14 Dysphagia, pharyngoesophageal phase
R13.19 Other dysphagia
R17 Unspecified jaundice
R22.2 Localized swelling, mass and lump, trunk
R59.0 Localized enlarged lymph nodes
R59.1 Generalized enlarged lymph nodes
R59.9 Enlarged lymph nodes, unspecified
R63.0 Anorexia
R63.39 Other feeding difficulties
R63.4 Abnormal weight loss
R68.89 Other general symptoms and signs
R93.2 Abnormal findings on diagnostic imaging of liver and biliary tract
R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
S11.20XA Unspecified open wound of pharynx and cervical esophagus, initial encounter
S11.20XD Unspecified open wound of pharynx and cervical esophagus, subsequent encounter
S11.20XS Unspecified open wound of pharynx and cervical esophagus, sequela
S11.21XA Laceration without foreign body of pharynx and cervical esophagus, initial encounter
S11.21XD Laceration without foreign body of pharynx and cervical esophagus, subsequent encounter
S11.21XS Laceration without foreign body of pharynx and cervical esophagus, sequela
S11.23XA Puncture wound without foreign body of pharynx and cervical esophagus, initial encounter
S11.23XD Puncture wound without foreign body of pharynx and cervical esophagus, subsequent encounter
S11.23XS Puncture wound without foreign body of pharynx and cervical esophagus, sequela
S11.25XA Open bite of pharynx and cervical esophagus, initial encounter
S11.25XD Open bite of pharynx and cervical esophagus, subsequent encounter
S11.25XS Open bite of pharynx and cervical esophagus, sequela
S21.309A Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, initial encounter
S21.309D Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, subsequent encounter
S21.309S Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, sequela
S27.812A Contusion of esophagus (thoracic part), initial encounter
S27.812D Contusion of esophagus (thoracic part), subsequent encounter
S27.812S Contusion of esophagus (thoracic part), sequela
S27.813A Laceration of esophagus (thoracic part), initial encounter
S27.813D Laceration of esophagus (thoracic part), subsequent encounter
S27.813S Laceration of esophagus (thoracic part), sequela
S27.818A Other injury of esophagus (thoracic part), initial encounter
S27.818D Other injury of esophagus (thoracic part), subsequent encounter
S27.818S Other injury of esophagus (thoracic part), sequela
S27.819A Unspecified injury of esophagus (thoracic part), initial encounter
S27.819D Unspecified injury of esophagus (thoracic part), subsequent encounter
S27.819S Unspecified injury of esophagus (thoracic part), sequela
T18.100A Unspecified foreign body in esophagus causing compression of trachea, initial encounter
T18.100D Unspecified foreign body in esophagus causing compression of trachea, subsequent encounter
T18.100S Unspecified foreign body in esophagus causing compression of trachea, sequela
T18.108A Unspecified foreign body in esophagus causing other injury, initial encounter
T18.108D Unspecified foreign body in esophagus causing other injury, subsequent encounter
T18.108S Unspecified foreign body in esophagus causing other injury, sequela
T18.110A Gastric contents in esophagus causing compression of trachea, initial encounter
T18.110D Gastric contents in esophagus causing compression of trachea, subsequent encounter
T18.110S Gastric contents in esophagus causing compression of trachea, sequela
T18.118A Gastric contents in esophagus causing other injury, initial encounter
T18.118D Gastric contents in esophagus causing other injury, subsequent encounter
T18.118S Gastric contents in esophagus causing other injury, sequela
T18.120A Food in esophagus causing compression of trachea, initial encounter
T18.120D Food in esophagus causing compression of trachea, subsequent encounter
T18.120S Food in esophagus causing compression of trachea, sequela
T18.128A Food in esophagus causing other injury, initial encounter
T18.128D Food in esophagus causing other injury, subsequent encounter
T18.128S Food in esophagus causing other injury, sequela
T18.190A Other foreign object in esophagus causing compression of trachea, initial encounter
T18.190D Other foreign object in esophagus causing compression of trachea, subsequent encounter
T18.190S Other foreign object in esophagus causing compression of trachea, sequela
T18.198A Other foreign object in esophagus causing other injury, initial encounter
T18.198D Other foreign object in esophagus causing other injury, subsequent encounter
T18.198S Other foreign object in esophagus causing other injury, sequela
T18.2XXA Foreign body in stomach, initial encounter
T18.2XXD Foreign body in stomach, subsequent encounter
T18.2XXS Foreign body in stomach, sequela
T18.3XXA Foreign body in small intestine, initial encounter
T18.3XXD Foreign body in small intestine, subsequent encounter
T18.3XXS Foreign body in small intestine, sequela
T18.4XXA Foreign body in colon, initial encounter
T18.4XXD Foreign body in colon, subsequent encounter
T18.4XXS Foreign body in colon, sequela
T28.0XXA Burn of mouth and pharynx, initial encounter
T28.0XXD Burn of mouth and pharynx, subsequent encounter
T28.0XXS Burn of mouth and pharynx, sequela
T28.1XXA Burn of esophagus, initial encounter
T28.1XXD Burn of esophagus, subsequent encounter
T28.1XXS Burn of esophagus, sequela
T28.2XXA Burn of other parts of alimentary tract, initial encounter
T28.2XXD Burn of other parts of alimentary tract, subsequent encounter
T28.2XXS Burn of other parts of alimentary tract, sequela
T28.5XXA Corrosion of mouth and pharynx, initial encounter
T28.5XXD Corrosion of mouth and pharynx, subsequent encounter
T28.5XXS Corrosion of mouth and pharynx, sequela
T28.6XXA Corrosion of esophagus, initial encounter
T28.6XXD Corrosion of esophagus, subsequent encounter
T28.6XXS Corrosion of esophagus, sequela
T28.7XXA Corrosion of other parts of alimentary tract, initial encounter
T28.7XXD Corrosion of other parts of alimentary tract, subsequent encounter
T28.7XXS Corrosion of other parts of alimentary tract, sequela
T54.1X1A Toxic effect of other corrosive organic compounds, accidental (unintentional), initial encounter
T54.1X1D Toxic effect of other corrosive organic compounds, accidental (unintentional), subsequent encounter
T54.1X1S Toxic effect of other corrosive organic compounds, accidental (unintentional), sequela
T54.1X2A Toxic effect of other corrosive organic compounds, intentional self-harm, initial encounter
T54.1X2D Toxic effect of other corrosive organic compounds, intentional self-harm, subsequent encounter
T54.1X2S Toxic effect of other corrosive organic compounds, intentional self-harm, sequela
T54.1X3A Toxic effect of other corrosive organic compounds, assault, initial encounter
T54.1X3D Toxic effect of other corrosive organic compounds, assault, subsequent encounter
T54.1X3S Toxic effect of other corrosive organic compounds, assault, sequela
T54.1X4A Toxic effect of other corrosive organic compounds, undetermined, initial encounter
T54.1X4D Toxic effect of other corrosive organic compounds, undetermined, subsequent encounter
T54.1X4S Toxic effect of other corrosive organic compounds, undetermined, sequela
T54.3X1A Toxic effect of corrosive alkalis and alkali-like substances, accidental (unintentional), initial encounter
T54.3X1D Toxic effect of corrosive alkalis and alkali-like substances, accidental (unintentional), subsequent encounter
T54.3X1S Toxic effect of corrosive alkalis and alkali-like substances, accidental (unintentional), sequela
T54.3X2A Toxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, initial encounter
T54.3X2D Toxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, subsequent encounter
T54.3X2S Toxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, sequela
T54.3X3A Toxic effect of corrosive alkalis and alkali-like substances, assault, initial encounter
T54.3X3D Toxic effect of corrosive alkalis and alkali-like substances, assault, subsequent encounter
T54.3X3S Toxic effect of corrosive alkalis and alkali-like substances, assault, sequela
T54.3X4A Toxic effect of corrosive alkalis and alkali-like substances, undetermined, initial encounter
T54.3X4D Toxic effect of corrosive alkalis and alkali-like substances, undetermined, subsequent encounter
T54.3X4S Toxic effect of corrosive alkalis and alkali-like substances, undetermined, sequela
T54.91XA Toxic effect of unspecified corrosive substance, accidental (unintentional), initial encounter
T54.91XD Toxic effect of unspecified corrosive substance, accidental (unintentional), subsequent encounter
T54.91XS Toxic effect of unspecified corrosive substance, accidental (unintentional), sequela
T54.92XA Toxic effect of unspecified corrosive substance, intentional self-harm, initial encounter
T54.92XD Toxic effect of unspecified corrosive substance, intentional self-harm, subsequent encounter
T54.92XS Toxic effect of unspecified corrosive substance, intentional self-harm, sequela
T54.93XA Toxic effect of unspecified corrosive substance, assault, initial encounter
T54.93XD Toxic effect of unspecified corrosive substance, assault, subsequent encounter
T54.93XS Toxic effect of unspecified corrosive substance, assault, sequela
T54.94XA Toxic effect of unspecified corrosive substance, undetermined, initial encounter
T54.94XD Toxic effect of unspecified corrosive substance, undetermined, subsequent encounter
T54.94XS Toxic effect of unspecified corrosive substance, undetermined, sequela
T57.1X1A Toxic effect of phosphorus and its compounds, accidental (unintentional), initial encounter
T57.1X1D Toxic effect of phosphorus and its compounds, accidental (unintentional), subsequent encounter
T57.1X1S Toxic effect of phosphorus and its compounds, accidental (unintentional), sequela
T57.1X2A Toxic effect of phosphorus and its compounds, intentional self-harm, initial encounter
T57.1X2D Toxic effect of phosphorus and its compounds, intentional self-harm, subsequent encounter
T57.1X2S Toxic effect of phosphorus and its compounds, intentional self-harm, sequela
T57.1X3A Toxic effect of phosphorus and its compounds, assault, initial encounter
T57.1X3D Toxic effect of phosphorus and its compounds, assault, subsequent encounter
T57.1X3S Toxic effect of phosphorus and its compounds, assault, sequela
T57.1X4A Toxic effect of phosphorus and its compounds, undetermined, initial encounter
T57.1X4D Toxic effect of phosphorus and its compounds, undetermined, subsequent encounter
T57.1X4S Toxic effect of phosphorus and its compounds, undetermined, sequela
Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z46.51* Encounter for fitting and adjustment of gastric lap band
Z46.59* Encounter for fitting and adjustment of other gastrointestinal appliance and device
Z79.01 Long term (current) use of anticoagulants
Z79.3 Long term (current) use of hormonal contraceptives
Z79.51 Long term (current) use of inhaled steroids
Z79.52 Long term (current) use of systemic steroids
Z79.82 Long term (current) use of aspirin
Z79.891 Long term (current) use of opiate analgesic
Z79.899 Other long term (current) drug therapy
Z85.00 Personal history of malignant neoplasm of unspecified digestive organ
Z85.01 Personal history of malignant neoplasm of esophagus
Z85.028 Personal history of other malignant neoplasm of stomach
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: Codes Z46.51 and Z46.59 are allowed only for CPT codes 43275 and 43276 for the removal of a biliary stent.

*Note: Diagnosis code E43 is allowed for CPT 43246 only.

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

Group 1

Group 1 Paragraph

All those not listed under the "ICD-10-CM Codes that Support Medical Necessity" section of this article.

Group 1 Codes

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ICD-10-PCS Codes

Group 1

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Group 1 Codes

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2024 R6

Article revised and published on 10/24/2024 effective for dates of service on and after 10/01/2024 to reflect Annual ICD-10-CM code updates. The following ICD-10-CM codes that Support Medical Necessity in Group 1 have been deleted and therefore have been removed from the article: C88.4. The following ICD-10-CM codes that Support Medical Necessity in Group 1 have been added to the article: C88.40. Minor formatting changes were made throughout the article.

01/09/2023 R5

Article revised and published on 04/06/2023 effective for dates of service on and after 01/09/2023 in response to an inquiry. The section ‘ICD-10-CM Codes that Support Medical Necessity, Group 1 Codes’ has been updated to add diagnoses codes D37.6 and R93.2. The third asterisk note regarding ICD-10 code R93.2 under ‘Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation’ has been deleted.

10/01/2021 R4

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been deleted and therefore removed from the Group 1 codes that support medical necessity: K22.8 and R63.3.
The following ICD-10-CM codes have been added to the Group 1 codes that support medical necessity: K22.81, K22.82, K22.89, K31.A11, K31.A12, K31.A13, K31.A14, K31.A15, K31.A19, K31.A21, K31.A22, and R63.39.

03/01/2021 R3

Article revised and published on 04/22/2021 effective for dates of service on and after 03/01/2021 due to an inquiry to add the following ICD-10-CM codes to the Group 1 ICD-10 codes that support medical necessity: C49.A1, C49.A2, C49.A3, C7A.092, C88.4, E10.43, E11.43, E13.43, and K31.84. Minor formatting revisions made throughout the article.

10/01/2020 R2

Article revised and published on 10/01/2020 effective for dates of service on and after 10/01/2020 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have been added to the Article Group 1 Codes: K20.80, K20.81, K20.90, K20.91, K21.00, and K21.01. The following ICD-10-CM codes have been deleted and therefore have been removed from the Article Group 1 Codes: K20.8, K20.9, and K21.0. Minor formatting revisions made throughout the article.

10/01/2019 R1

Article revised and published on 10/17/2019 effective for dates of service on and after 10/01/2019 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code has been added to Group 1 ICD-10-CM codes in the article: R11.15. System changes have been made to our articles in response to CMS Change Request 10901. The Coding Section has been reordered and new sections for CPT/HCPCS Modifiers and Other Coding Information have been added.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
NCDs
100.2 - Endoscopy
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Updated On Effective Dates Status
10/18/2024 10/01/2024 - N/A Currently in Effect You are here
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