LCD Reference Article Billing and Coding Article

Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

A56394

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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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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56394
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic
Article Type
Billing and Coding
Original Effective Date
03/28/2019
Revision Effective Date
02/29/2024
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

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.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article only applies to diagnostic colonoscopies and sigmoidoscopies. Sigmoidoscopy and colonoscopy testing allows for the direct visualization of the lower gastrointestinal tract. Inspection is performed with an illuminated tube. These procedures are performed to detect polyps, tumors and other lesions of the intestines. The site of pathology can be identified during a colonoscopy and a biopsy can be obtained. Refer to associated LCD L34614.

Refer to the Medicare Internet Only Manuals (IOM) for coverage of colorectal cancer screening procedures.

Documentation Requirements
The medical record should support the medical reasonableness, necessity and frequency of the diagnostic test performed. This documentation should be made available to the Contractor upon request.

Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.

Utilization Guidelines
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
013x Hospital Outpatient
014x Hospital - Laboratory Services Provided to Non-patients
071x Clinic - Rural Health
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
032X Radiology - Diagnostic - General Classification
036X Operating Room Services - General Classification
0450 Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
0750 Gastro-Intestinal (GI) Services - General Classification
076X Specialty Services - General Classification
N/A

CPT/HCPCS Codes

Group 1

(35 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
44388 COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
44389 COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE
44390 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF FOREIGN BODY(S)
44391 COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING, ANY METHOD
44392 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS
44394 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE
44401 COLONOSCOPY THROUGH STOMA; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE-AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)
44402 COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC STENT PLACEMENT (INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)
44403 COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC MUCOSAL RESECTION
44404 COLONOSCOPY THROUGH STOMA; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE
44405 COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC BALLOON DILATION
44406 COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, LIMITED TO THE SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM AND ADJACENT STRUCTURES
44407 COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM AND ADJACENT STRUCTURES
44408 COLONOSCOPY THROUGH STOMA; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED
45330 SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
45331 SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE
45332 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)
45333 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS
45334 SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD
45335 SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE
45337 SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED
45338 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE
45340 SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION
45341 SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION
45342 SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)
45378 COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
45379 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)
45380 COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE
45381 COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE
45382 COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD
45384 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS
45385 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE
45386 COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION
45391 COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES
45392 COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(313 Codes)
Group 1 Paragraph

ICD-10 codes must be coded to the highest level of specificity

Group 1 Codes
Code Description
A04.3 Enterohemorrhagic Escherichia coli infection
A04.5 Campylobacter enteritis
A04.71 Enterocolitis due to Clostridium difficile, recurrent
A04.72 Enterocolitis due to Clostridium difficile, not specified as recurrent
A06.1 Chronic intestinal amebiasis
A06.2 Amebic nondysenteric colitis
A06.9 Amebiasis, unspecified
A09 Infectious gastroenteritis and colitis, unspecified
A18.31 Tuberculous peritonitis
A18.32 Tuberculous enteritis
A18.39 Retroperitoneal tuberculosis
A18.83 Tuberculosis of digestive tract organs, not elsewhere classified
B20 Human immunodeficiency virus [HIV] disease
B95.1 Streptococcus, group B, as the cause of diseases classified elsewhere
B95.2 Enterococcus as the cause of diseases classified elsewhere
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.0 Malignant neoplasm of anus, unspecified
C21.1 Malignant neoplasm of anal canal
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C26.0 Malignant neoplasm of intestinal tract, part unspecified
C26.9 Malignant neoplasm of ill-defined sites within the digestive system
C49.A3 Gastrointestinal stromal tumor of small intestine
C49.A4 Gastrointestinal stromal tumor of large intestine
C49.A5 Gastrointestinal stromal tumor of rectum
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.019 Malignant carcinoid tumor of the small intestine, unspecified portion
C7A.020 Malignant carcinoid tumor of the appendix
C7A.021 Malignant carcinoid tumor of the cecum
C7A.022 Malignant carcinoid tumor of the ascending colon
C7A.023 Malignant carcinoid tumor of the transverse colon
C7A.024 Malignant carcinoid tumor of the descending colon
C7A.025 Malignant carcinoid tumor of the sigmoid colon
C7A.026 Malignant carcinoid tumor of the rectum
C7A.029 Malignant carcinoid tumor of the large intestine, unspecified portion
C76.3 Malignant neoplasm of pelvis
C77.2 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C80.0 Disseminated malignant neoplasm, unspecified
D00.1 Carcinoma in situ of esophagus
D00.2 Carcinoma in situ of stomach
D01.0 Carcinoma in situ of colon
D01.1 Carcinoma in situ of rectosigmoid junction
D01.2 Carcinoma in situ of rectum
D01.3 Carcinoma in situ of anus and anal canal
D12.0 Benign neoplasm of cecum
D12.1 Benign neoplasm of appendix
D12.2 Benign neoplasm of ascending colon
D12.3 Benign neoplasm of transverse colon
D12.4 Benign neoplasm of descending colon
D12.5 Benign neoplasm of sigmoid colon
D12.6 Benign neoplasm of colon, unspecified
D12.7 Benign neoplasm of rectosigmoid junction
D12.8 Benign neoplasm of rectum
D12.9 Benign neoplasm of anus and anal canal
D13.91 Familial adenomatous polyposis
D3A.010 Benign carcinoid tumor of the duodenum
D3A.011 Benign carcinoid tumor of the jejunum
D3A.012 Benign carcinoid tumor of the ileum
D3A.019 Benign carcinoid tumor of the small intestine, unspecified portion
D3A.020 Benign carcinoid tumor of the appendix
D3A.021 Benign carcinoid tumor of the cecum
D3A.022 Benign carcinoid tumor of the ascending colon
D3A.023 Benign carcinoid tumor of the transverse colon
D3A.024 Benign carcinoid tumor of the descending colon
D3A.025 Benign carcinoid tumor of the sigmoid colon
D3A.026 Benign carcinoid tumor of the rectum
D3A.029 Benign carcinoid tumor of the large intestine, unspecified portion
D3A.096 Benign carcinoid tumor of the hindgut, unspecified
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
D37.8 Neoplasm of uncertain behavior of other specified digestive organs
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
I33.0 Acute and subacute infective endocarditis
I78.0 Hereditary hemorrhagic telangiectasia
K50.00 Crohn's disease of small intestine without complications
K50.011 Crohn's disease of small intestine with rectal bleeding
K50.012 Crohn's disease of small intestine with intestinal obstruction
K50.013 Crohn's disease of small intestine with fistula
K50.014 Crohn's disease of small intestine with abscess
K50.018 Crohn's disease of small intestine with other complication
K50.019 Crohn's disease of small intestine with unspecified complications
K50.10 Crohn's disease of large intestine without complications
K50.111 Crohn's disease of large intestine with rectal bleeding
K50.112 Crohn's disease of large intestine with intestinal obstruction
K50.113 Crohn's disease of large intestine with fistula
K50.114 Crohn's disease of large intestine with abscess
K50.118 Crohn's disease of large intestine with other complication
K50.119 Crohn's disease of large intestine with unspecified complications
K50.80 Crohn's disease of both small and large intestine without complications
K50.811 Crohn's disease of both small and large intestine with rectal bleeding
K50.812 Crohn's disease of both small and large intestine with intestinal obstruction
K50.813 Crohn's disease of both small and large intestine with fistula
K50.814 Crohn's disease of both small and large intestine with abscess
K50.818 Crohn's disease of both small and large intestine with other complication
K50.819 Crohn's disease of both small and large intestine with unspecified complications
K50.90 Crohn's disease, unspecified, without complications
K50.911 Crohn's disease, unspecified, with rectal bleeding
K50.912 Crohn's disease, unspecified, with intestinal obstruction
K50.913 Crohn's disease, unspecified, with fistula
K50.914 Crohn's disease, unspecified, with abscess
K50.918 Crohn's disease, unspecified, with other complication
K50.919 Crohn's disease, unspecified, with unspecified complications
K51.00 Ulcerative (chronic) pancolitis without complications
K51.011 Ulcerative (chronic) pancolitis with rectal bleeding
K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction
K51.013 Ulcerative (chronic) pancolitis with fistula
K51.014 Ulcerative (chronic) pancolitis with abscess
K51.018 Ulcerative (chronic) pancolitis with other complication
K51.019 Ulcerative (chronic) pancolitis with unspecified complications
K51.20 Ulcerative (chronic) proctitis without complications
K51.211 Ulcerative (chronic) proctitis with rectal bleeding
K51.212 Ulcerative (chronic) proctitis with intestinal obstruction
K51.213 Ulcerative (chronic) proctitis with fistula
K51.214 Ulcerative (chronic) proctitis with abscess
K51.218 Ulcerative (chronic) proctitis with other complication
K51.219 Ulcerative (chronic) proctitis with unspecified complications
K51.30 Ulcerative (chronic) rectosigmoiditis without complications
K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding
K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction
K51.313 Ulcerative (chronic) rectosigmoiditis with fistula
K51.314 Ulcerative (chronic) rectosigmoiditis with abscess
K51.318 Ulcerative (chronic) rectosigmoiditis with other complication
K51.319 Ulcerative (chronic) rectosigmoiditis with unspecified complications
K51.40 Inflammatory polyps of colon without complications
K51.411 Inflammatory polyps of colon with rectal bleeding
K51.412 Inflammatory polyps of colon with intestinal obstruction
K51.413 Inflammatory polyps of colon with fistula
K51.414 Inflammatory polyps of colon with abscess
K51.418 Inflammatory polyps of colon with other complication
K51.419 Inflammatory polyps of colon with unspecified complications
K51.50 Left sided colitis without complications
K51.511 Left sided colitis with rectal bleeding
K51.512 Left sided colitis with intestinal obstruction
K51.513 Left sided colitis with fistula
K51.514 Left sided colitis with abscess
K51.518 Left sided colitis with other complication
K51.519 Left sided colitis with unspecified complications
K51.80 Other ulcerative colitis without complications
K51.811 Other ulcerative colitis with rectal bleeding
K51.812 Other ulcerative colitis with intestinal obstruction
K51.813 Other ulcerative colitis with fistula
K51.814 Other ulcerative colitis with abscess
K51.818 Other ulcerative colitis with other complication
K51.819 Other ulcerative colitis with unspecified complications
K51.90 Ulcerative colitis, unspecified, without complications
K51.911 Ulcerative colitis, unspecified with rectal bleeding
K51.912 Ulcerative colitis, unspecified with intestinal obstruction
K51.913 Ulcerative colitis, unspecified with fistula
K51.914 Ulcerative colitis, unspecified with abscess
K51.918 Ulcerative colitis, unspecified with other complication
K51.919 Ulcerative colitis, unspecified with unspecified complications
K52.0 Gastroenteritis and colitis due to radiation
K52.1 Toxic gastroenteritis and colitis
K52.21 Food protein-induced enterocolitis syndrome
K52.22 Food protein-induced enteropathy
K52.29 Other allergic and dietetic gastroenteritis and colitis
K52.3 Indeterminate colitis
K52.82 Eosinophilic colitis
K52.831 Collagenous colitis
K52.832 Lymphocytic colitis
K52.838 Other microscopic colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
K55.011 Focal (segmental) acute (reversible) ischemia of small intestine
K55.012 Diffuse acute (reversible) ischemia of small intestine
K55.019 Acute (reversible) ischemia of small intestine, extent unspecified
K55.021 Focal (segmental) acute infarction of small intestine
K55.022 Diffuse acute infarction of small intestine
K55.029 Acute infarction of small intestine, extent unspecified
K55.031 Focal (segmental) acute (reversible) ischemia of large intestine
K55.032 Diffuse acute (reversible) ischemia of large intestine
K55.039 Acute (reversible) ischemia of large intestine, extent unspecified
K55.041 Focal (segmental) acute infarction of large intestine
K55.042 Diffuse acute infarction of large intestine
K55.049 Acute infarction of large intestine, extent unspecified
K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified
K55.052 Diffuse acute (reversible) ischemia of intestine, part unspecified
K55.061 Focal (segmental) acute infarction of intestine, part unspecified
K55.062 Diffuse acute infarction of intestine, part unspecified
K55.1 Chronic vascular disorders of intestine
K55.20 Angiodysplasia of colon without hemorrhage
K55.21 Angiodysplasia of colon with hemorrhage
K55.30 Necrotizing enterocolitis, unspecified
K55.31 Stage 1 necrotizing enterocolitis
K55.32 Stage 2 necrotizing enterocolitis
K55.33 Stage 3 necrotizing enterocolitis
K55.8 Other vascular disorders of intestine
K55.9 Vascular disorder of intestine, unspecified
K56.0 Paralytic ileus
K56.1 Intussusception
K56.2 Volvulus
K56.50 Intestinal adhesions [bands], unspecified as to partial versus complete obstruction
K56.51 Intestinal adhesions [bands], with partial obstruction
K56.52 Intestinal adhesions [bands] with complete obstruction
K56.600 Partial intestinal obstruction, unspecified as to cause
K56.601 Complete intestinal obstruction, unspecified as to cause
K56.609 Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction
K56.690 Other partial intestinal obstruction
K56.691 Other complete intestinal obstruction
K56.699 Other intestinal obstruction unspecified as to partial versus complete obstruction
K56.7 Ileus, unspecified
K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding
K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding
K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding
K57.31 Diverticulosis of large intestine without perforation or abscess with bleeding
K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding
K57.33 Diverticulitis of large intestine without perforation or abscess with bleeding
K57.40 Diverticulitis of both small and large intestine with perforation and abscess without bleeding
K57.41 Diverticulitis of both small and large intestine with perforation and abscess with bleeding
K57.50 Diverticulosis of both small and large intestine without perforation or abscess without bleeding
K57.51 Diverticulosis of both small and large intestine without perforation or abscess with bleeding
K57.52 Diverticulitis of both small and large intestine without perforation or abscess without bleeding
K57.53 Diverticulitis of both small and large intestine without perforation or abscess with bleeding
K57.80 Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding
K57.81 Diverticulitis of intestine, part unspecified, with perforation and abscess with bleeding
K57.90 Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding
K57.91 Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding
K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding
K57.93 Diverticulitis of intestine, part unspecified, without perforation or abscess with bleeding
K58.1 Irritable bowel syndrome with constipation
K58.2 Mixed irritable bowel syndrome
K58.8 Other irritable bowel syndrome
K59.03 Drug induced constipation
K59.04 Chronic idiopathic constipation
K59.1 Functional diarrhea
K59.2 Neurogenic bowel, not elsewhere classified
K59.31 Toxic megacolon
K59.39 Other megacolon
K59.4 Anal spasm
K59.81 Ogilvie syndrome
K59.89 Other specified functional intestinal disorders
K62.0 Anal polyp
K62.1 Rectal polyp
K62.5 Hemorrhage of anus and rectum
K63.1 Perforation of intestine (nontraumatic)
K63.2 Fistula of intestine
K63.3 Ulcer of intestine
K63.4 Enteroptosis
K63.5 Polyp of colon
K63.81 Dieulafoy lesion of intestine
K63.8211 Small intestinal bacterial overgrowth, hydrogen-subtype
K63.8212 Small intestinal bacterial overgrowth, hydrogen sulfide-subtype
K63.8219 Small intestinal bacterial overgrowth, unspecified
K63.822 Small intestinal fungal overgrowth
K63.829 Intestinal methanogen overgrowth, unspecified
K63.89 Other specified diseases of intestine
K91.30 Postprocedural intestinal obstruction, unspecified as to partial versus complete
K91.31 Postprocedural partial intestinal obstruction
K91.32 Postprocedural complete intestinal obstruction
K91.89 Other postprocedural complications and disorders of digestive system
K92.1 Melena
K92.2 Gastrointestinal hemorrhage, unspecified
K92.81 Gastrointestinal mucositis (ulcerative)
K92.89 Other specified diseases of the digestive system
L83 Acanthosis nigricans
N32.1 Vesicointestinal fistula
N82.2 Fistula of vagina to small intestine
N82.3 Fistula of vagina to large intestine
N82.4 Other female intestinal-genital tract fistulae
Q85.81 PTEN hamartoma tumor syndrome
Q85.82 Other Cowden syndrome
Q85.83 Von Hippel-Lindau syndrome
Q85.89 Other phakomatoses, not elsewhere classified
Q85.9 Phakomatosis, unspecified
R11.13 Vomiting of fecal matter
R19.4 Change in bowel habit
R19.5 Other fecal abnormalities
R19.7 Diarrhea, unspecified
R19.8 Other specified symptoms and signs involving the digestive system and abdomen
R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
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
T18.5XXA Foreign body in anus and rectum, initial encounter
T18.5XXD Foreign body in anus and rectum, subsequent encounter
T18.5XXS Foreign body in anus and rectum, sequela
Z85.01 Personal history of malignant neoplasm of esophagus
Z85.028 Personal history of other malignant neoplasm of stomach
Z85.030 Personal history of malignant carcinoid tumor of large intestine
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.040 Personal history of malignant carcinoid tumor of rectum
Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z85.05 Personal history of malignant neoplasm of liver
Z85.060 Personal history of malignant carcinoid tumor of small intestine
Z85.068 Personal history of other malignant neoplasm of small intestine
Z86.004 Personal history of in-situ neoplasm of other and unspecified digestive organs
Z86.010 Personal history of colonic polyps
Z86.012 Personal history of benign carcinoid tumor
Z87.19 Personal history of other diseases of the digestive system
N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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Additional ICD-10 Information

N/A

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
013x Hospital Outpatient
014x Hospital - Laboratory Services Provided to Non-patients
071x Clinic - Rural Health
085x Critical Access Hospital
N/A

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
032X Radiology - Diagnostic - General Classification
036X Operating Room Services - General Classification
0450 Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
0750 Gastro-Intestinal (GI) Services - General Classification
076X Specialty Services - General Classification
N/A

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
N/A N/A
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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
02/29/2024 R6

Posted 2/29/2024 Under ICD-10 Codes that Support Medical Necessity Group 1 Codes added ICD-10 code D13.91.

10/01/2023 R5

Posted 09/28/2023. 2024 ICD-10-CM Code annual update. Under ICD-10 Codes that Support Medical Necessity Group 1 Codes added K63.8211, K63.8212, K63.8219, K63.822 and K63.829 and updated description for Q85.81 effective 10/01/2023.

10/01/2022 R4

Posted 09/29/2022 ICD-10 CM Code annual update. Group 1 deleted Q85.8 and added Q85.81, Q85.82, Q85.83 and Q85.89 effective 10/01/2022. Review completed 8/16/2022.

10/01/2020 R3

10/01/2020 ICD-10 CM Code annual update. Group 1: deleted K59.8 and added K59.81 and K59.89. Review completed 09/02/2020.

11/01/2019 R2

Content has been moved to the new template.

09/26/2019 R1

09/26/2019: Please note Title change: Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic. Request for coverage by a Practitioner (Part B): ICD-10 codes added to Group 1 codes: C7A.010, C7A.011, C7A.012, C7A.019, D3A.010, D3A.011, D3A.012, D3A.019, D3A.029, Z85.030, Z85.040, Z85.060, Z85.068, and Z86.012. ICD-10 CM Code annual update: Group 1 Codes: added Z86.004 effective 10/01/2019.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L34614 - Colonoscopy and Sigmoidoscopy-Diagnostic
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
https://www.ssa.gov/OP_Home/ssact/title18/1862.htm
Description: Title XVIII of the Social Security Act (SSA or the Act), Section 1862(a)(1)(A), explains that payment may be allowed only for those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
https://www.ssa.gov/OP_Home/ssact/title18/1833.htm
Description: Title XVIII of the SSA, Section 1833(e), prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
https://www.ssa.gov/OP_Home/ssact/title18/1862.htm
Description: Title XVIII of the SSA, Section 1862(a)(7), states that Medicare will not cover any services or procedures associated with routine physical checkups.
https://www.ssa.gov/OP_Home/ssact/title18/1862.htm
Description: 42 Code of Federal Regulations, 410.32, Diagnostic X-Rays, diagnostic laboratory tests, and other diagnostic tests: Conditions. This section describes regulations that apply to performing these tests.
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CMS Manual Explanations URLs
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
Description: Pub 100-02, Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services: Section 80-Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, Section 280.2 -Colorectal Cancer Screening
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
Description: Pub.100-04 Medicare Claims Processing Manual -Chapter 18 Preventive and Screening Services: Section 60 - Colorectal Cancer Screening
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Other URLs
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Updated On Effective Dates Status
02/21/2024 02/29/2024 - N/A Currently in Effect You are here
09/19/2023 10/01/2023 - 02/28/2024 Superseded View
09/20/2022 10/01/2022 - 09/30/2023 Superseded View
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