LCD Reference Article Billing and Coding Article

Billing and Coding: Colon Capsule Endoscopy (CCE)

A58436

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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.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A58436
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Colon Capsule Endoscopy (CCE)
Article Type
Billing and Coding
Original Effective Date
03/28/2021
Revision Effective Date
01/01/2022
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) L38824, Colon Capsule Endoscopy (CCE). Please refer to the LCD for reasonable and necessary requirements.

Coding Information:

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.

For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis code Z53.8 indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis code Z53.09 indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.

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.

 

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
Code Description
91113 Gi trc img intral colon i&r
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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

(6 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.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 91113.

Group 1 Codes
Code Description
K63.5* Polyp of colon
K92.1* Melena
K92.2* Gastrointestinal hemorrhage, unspecified
R19.5* Other fecal abnormalities
Z53.09* Procedure and treatment not carried out because of other contraindication
Z53.8* Procedure and treatment not carried out for other reasons
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Z53.09 or Z53.8 must be reported with either K63.5, K92.1, K92.2, or R19.5.

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

Group 1

(1 Code)
Group 1 Paragraph

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

Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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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
999x Not Applicable
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.

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Code Description
99999 Not Applicable
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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
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
01/01/2022 R3

Updated to indicate this article is an LCD Reference Article

01/01/2022 R2

Due to the 2022 CPT/HCPCS updates, 0355T will be deleted effective 12/31/2021 and replaced with 91113 effective 0/01/2022.

12/19/2021 R1

The LCD was revised with an effective date of 12/19/2021 to acknowledge updated FDA approval, blood-based biomarker testing that could be used for screening purposes. No revision was made to the Billing and Coding article other than the revised effective date to be consistent with the LCD.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/16/2023 01/01/2022 - N/A Currently in Effect You are here
12/21/2021 01/01/2022 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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