SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

A56456

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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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General Information

Source Article ID
N/A
Article ID
A56456
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Article Type
Billing and Coding
Original Effective Date
10/01/2018
Revision Effective Date
01/26/2023
Revision Ending Date
11/15/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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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.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy for L34005-Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy.

 

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
0450 Emergency Room - General Classification
0490 Ambulatory Surgical Care - General Classification
0510 Clinic - General Classification
0514 Clinic - OB-GYN Clinic
0515 Clinic - Pediatric Clinic
0516 Clinic - Urgent Care Clinic
0517 Clinic - Family Practice Clinic
0519 Clinic - Other Clinic
0750 Gastro-Intestinal (GI) Services - General Classification
0760 Specialty Services - General Classification
0960 Professional Fees - General Classification
0969 Professional Fees - Other Professional Fee
0972 Professional Fees - Radiology - Diagnostic
0973 Professional Fees - Radiology - Therapeutic
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic
N/A

CPT/HCPCS Codes

Group 1

(45 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)
45300 PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)
45303 PROCTOSIGMOIDOSCOPY, RIGID; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)
45305 PROCTOSIGMOIDOSCOPY, RIGID; WITH BIOPSY, SINGLE OR MULTIPLE
45307 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF FOREIGN BODY
45308 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY
45309 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY SNARE TECHNIQUE
45315 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS, OR OTHER LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE
45317 PROCTOSIGMOIDOSCOPY, RIGID; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)
45320 PROCTOSIGMOIDOSCOPY, RIGID; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE (EG, LASER)
45321 PROCTOSIGMOIDOSCOPY, RIGID; WITH DECOMPRESSION OF VOLVULUS
45327 PROCTOSIGMOIDOSCOPY, RIGID; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION)
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)
45346 SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)
45347 SIGMOIDOSCOPY, FLEXIBLE; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)
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
45388 COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)
45389 COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC STENT PLACEMENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)
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
45399 UNLISTED PROCEDURE, COLON
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

(401 Codes)
Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Please note: For the purposes of this LCD, each ICD-10-CM code listed in this paragraph represents only the condition as noted during colonoscopy/sigmoidoscopy/proctosigmoidoscopy and should only be reported when that condition exists in the colon, A03.9, A07.3, A09, A54.6, B65.1, B68.0, B68.1, B71.1, B71.8, D17.5, D17.71, D18.03, D18.1, D49.0, I86.4, K56.49, K56.3, K57.10, K57.11, K57.50, K57.51, Q43.3.

Please note: For the purposes of this policy ICD-10-CM code K92.2 also represents portal hypertensive colopathy.

ICD-10-CM codes D37.1-D37.5, K50.00, K50.011-K50.014, K50.018, K50.10, K50.111-K50.114, K50.118, K50.80, K50.811-K50.814, K50.818, K50.90, K50.911-K50.914, K50.918, K51.00, K51.011-K51.014, K51.018, K51.80, K51.20, K51.211-K51.214, k51.218, K51.30, K51.311-K51.314, K51.318, K51.40, K51.411-K51.414, K51.418, K51.50, K51.511-K51.514, K51.518, K51.80, K51.811-K51.814, K51.818, K51.90, K51.911-K51.914, K51.918, K52.1, K52.2, K52.81-K52.82 and K52.89 can be utilized both as indications for colonoscopy/sigmoidoscopy/proctosigmoidoscopy or as indications for Colorectal Cancer Screening.

Surveillance of colonic neoplasia requires the primary diagnosis of ICD-10-CM code Z08 and a secondary diagnosis of Z85.038, Z85.048,or Z86.010. 

Group 1 Codes
Code Description
A03.9 Shigellosis, unspecified
A04.3 Enterohemorrhagic Escherichia coli infection
A04.5 - A04.9 Campylobacter enteritis - Bacterial intestinal infection, unspecified
A06.1 Chronic intestinal amebiasis
A06.2 Amebic nondysenteric colitis
A06.9 Amebiasis, unspecified
A07.0 Balantidiasis
A07.3 Isosporiasis
A07.8 Other specified protozoal intestinal diseases
A08.0 Rotaviral enteritis
A08.11 Acute gastroenteropathy due to Norwalk agent
A08.19 Acute gastroenteropathy due to other small round viruses
A08.2 Adenoviral enteritis
A08.31 Calicivirus enteritis
A08.32 Astrovirus enteritis
A08.39 Other viral enteritis
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
A54.6 Gonococcal infection of anus and rectum
A55 Chlamydial lymphogranuloma (venereum)
B20 Human immunodeficiency virus [HIV] disease
B37.82 Candidal enteritis
B65.1 Schistosomiasis due to Schistosoma mansoni [intestinal schistosomiasis]
B68.0 Taenia solium taeniasis
B68.1 Taenia saginata taeniasis
B68.9 Taeniasis, unspecified
B70.0 Diphyllobothriasis
B71.0 Hymenolepiasis
B71.1 Dipylidiasis
B71.8 Other specified cestode infections
B76.8 Other hookworm diseases
B76.9 Hookworm disease, unspecified
B77.0 Ascariasis with intestinal complications
B77.81 Ascariasis pneumonia
B77.89 Ascariasis with other complications
B78.0 Intestinal strongyloidiasis
B78.7 Disseminated strongyloidiasis
B79 Trichuriasis
B80 Enterobiasis
B82.0 Intestinal helminthiasis, unspecified
B82.9 Intestinal parasitism, unspecified
B83.9 Helminthiasis, unspecified
C17.2 Malignant neoplasm of ileum
C18.0 - C18.9 Malignant neoplasm of cecum - 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
C7A.00 Malignant carcinoid tumor of unspecified site
C7A.020 - C7A.026 Malignant carcinoid tumor of the appendix - Malignant carcinoid tumor of the rectum
C7A.029 Malignant carcinoid tumor of the large intestine, unspecified portion
C7A.096 Malignant carcinoid tumor of the hindgut, unspecified
C7A.098 Malignant carcinoid tumors of other sites
C7A.1 Malignant poorly differentiated neuroendocrine tumors
C7A.8 Other malignant neuroendocrine tumors
C7B.04 Secondary carcinoid tumors of peritoneum
C7B.09 Secondary carcinoid tumors of other sites
C7B.1 Secondary Merkel cell carcinoma
C77.2 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
C78.4 Secondary malignant neoplasm of small intestine
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
D01.0 - D01.3 Carcinoma in situ of colon - Carcinoma in situ of anus and anal canal
D12.0 - D12.9 Benign neoplasm of cecum - Benign neoplasm of anus and anal canal
D17.5 Benign lipomatous neoplasm of intra-abdominal organs
D17.71 Benign lipomatous neoplasm of kidney
D18.03 Hemangioma of intra-abdominal structures
D18.1 Lymphangioma, any site
D3A.00 Benign carcinoid tumor of unspecified site
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
D37.1 - D37.5 Neoplasm of uncertain behavior of stomach - 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
I77.2 Rupture of artery
I78.0 Hereditary hemorrhagic telangiectasia
I86.4 Gastric varices
K35.80 Unspecified acute appendicitis
K35.890 Other acute appendicitis without perforation or gangrene
K35.891 Other acute appendicitis without perforation, with gangrene
K38.0 - K38.3 Hyperplasia of appendix - Fistula of appendix
K50.00 Crohn's disease of small intestine without complications
K50.011 - K50.014 Crohn's disease of small intestine with rectal bleeding - Crohn's disease of small intestine with abscess
K50.018 Crohn's disease of small intestine with other complication
K50.10 Crohn's disease of large intestine without complications
K50.111 - K50.114 Crohn's disease of large intestine with rectal bleeding - Crohn's disease of large intestine with abscess
K50.118 Crohn's disease of large intestine with other complication
K50.80 Crohn's disease of both small and large intestine without complications
K50.811 - K50.814 Crohn's disease of both small and large intestine with rectal bleeding - 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
K50.90 Crohn's disease, unspecified, without complications
K50.911 - K50.914 Crohn's disease, unspecified, with rectal bleeding - Crohn's disease, unspecified, with abscess
K50.918 Crohn's disease, unspecified, with other complication
K51.00 Ulcerative (chronic) pancolitis without complications
K51.011 - K51.014 Ulcerative (chronic) pancolitis with rectal bleeding - Ulcerative (chronic) pancolitis with abscess
K51.018 Ulcerative (chronic) pancolitis with other complication
K51.20 Ulcerative (chronic) proctitis without complications
K51.211 - K51.214 Ulcerative (chronic) proctitis with rectal bleeding - Ulcerative (chronic) proctitis with abscess
K51.218 Ulcerative (chronic) proctitis with other complication
K51.30 Ulcerative (chronic) rectosigmoiditis without complications
K51.311 - K51.314 Ulcerative (chronic) rectosigmoiditis with rectal bleeding - Ulcerative (chronic) rectosigmoiditis with abscess
K51.318 Ulcerative (chronic) rectosigmoiditis with other complication
K51.40 Inflammatory polyps of colon without complications
K51.411 - K51.414 Inflammatory polyps of colon with rectal bleeding - Inflammatory polyps of colon with abscess
K51.418 Inflammatory polyps of colon with other complication
K51.50 Left sided colitis without complications
K51.511 - K51.514 Left sided colitis with rectal bleeding - Left sided colitis with abscess
K51.518 Left sided colitis with other complication
K51.80 Other ulcerative colitis without complications
K51.811 - K51.814 Other ulcerative colitis with rectal bleeding - Other ulcerative colitis with abscess
K51.818 Other ulcerative colitis with other complication
K51.90 Ulcerative colitis, unspecified, without complications
K51.911 - K51.914 Ulcerative colitis, unspecified with rectal bleeding - Ulcerative colitis, unspecified with abscess
K51.918 Ulcerative colitis, unspecified with other complication
K52.0 - K52.1 Gastroenteritis and colitis due to radiation - 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
K52.81 Eosinophilic gastritis or gastroenteritis
K52.82 Eosinophilic 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
K55.021 Focal (segmental) acute infarction of small intestine
K55.022 Diffuse acute infarction of small intestine
K55.031 Focal (segmental) acute (reversible) ischemia of large intestine
K55.032 Diffuse acute (reversible) ischemia of large intestine
K55.041 Focal (segmental) acute infarction of large intestine
K55.042 Diffuse acute infarction of large intestine
K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified
K55.052 Diffuse acute (reversible) ischemia 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
K55.9 Vascular disorder of intestine, unspecified
K56.0 - K56.3 Paralytic ileus - Gallstone ileus
K56.49 Other impaction of intestine
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
K56.690 Other partial intestinal obstruction
K56.691 Other complete intestinal obstruction
K56.699 Other intestinal obstruction unspecified as to partial versus complete obstruction
K57.00 Diverticulitis of small intestine with perforation and abscess without bleeding
K57.01 Diverticulitis of small intestine with perforation and abscess with bleeding
K57.10 Diverticulosis of small intestine without perforation or abscess without bleeding
K57.11 Diverticulosis of small intestine without perforation or abscess with bleeding
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 - K57.33 Diverticulosis of large intestine without perforation or abscess without bleeding - 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 - K57.53 Diverticulosis of both small and large intestine without perforation or abscess without bleeding - 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
K58.0 Irritable bowel syndrome with diarrhea
K58.9 Irritable bowel syndrome without diarrhea
K59.00 - K59.02 Constipation, unspecified - Outlet dysfunction constipation
K59.09 Other constipation
K59.1 - K59.2 Functional diarrhea - Neurogenic bowel, not elsewhere classified
K59.31 Toxic megacolon
K59.39 Other megacolon
K59.81 Ogilvie syndrome
K62.0 Anal polyp
K62.1 Rectal polyp
K62.4 - K62.6 Stenosis of anus and rectum - Ulcer of anus and rectum
K62.81 Anal sphincter tear (healed) (nontraumatic) (old)
K62.82 Dysplasia of anus
K63.0 - K63.5 Abscess of intestine - Polyp of colon
K63.81 Dieulafoy lesion of intestine
K63.89 Other specified diseases of intestine
K64.0 - K64.3 First degree hemorrhoids - Fourth degree hemorrhoids
K80.32 - K80.37 Calculus of bile duct with acute cholangitis without obstruction - Calculus of bile duct with acute and chronic cholangitis with obstruction
K83.01 Primary sclerosing cholangitis
K83.09 Other cholangitis
K90.41 Non-celiac gluten sensitivity
K90.49 Malabsorption due to intolerance, not elsewhere classified
K90.89 Other intestinal malabsorption
K91.850 Pouchitis
K91.858 Other complications of intestinal pouch
K91.89 Other postprocedural complications and disorders of digestive system
K92.1 Melena
K92.2 Gastrointestinal hemorrhage, unspecified
K92.89 Other specified diseases of the digestive system
K94.00 Colostomy complication, unspecified
K94.01 Colostomy hemorrhage
K94.03 Colostomy malfunction
K94.10 Enterostomy complication, unspecified
K94.11 Enterostomy hemorrhage
K94.13 Enterostomy malfunction
N28.89 Other specified disorders of kidney and ureter
N32.1 Vesicointestinal fistula
N82.2 - N82.4 Fistula of vagina to small intestine - Other female intestinal-genital tract fistulae
Q42.0 - Q42.3 Congenital absence, atresia and stenosis of rectum with fistula - Congenital absence, atresia and stenosis of anus without fistula
Q42.8 Congenital absence, atresia and stenosis of other parts of large intestine
Q43.1 - Q43.8 Hirschsprung's disease - Other specified congenital malformations of intestine
Q85.81 PTEN tumor syndrome
Q85.82 Other Cowden syndrome
Q85.83 Von Hippel-Lindau syndrome
Q85.89 Other phakomatoses, not elsewhere classified
R10.11 - R10.13 Right upper quadrant pain - Epigastric pain
R10.2 Pelvic and perineal pain
R10.31 - R10.33 Right lower quadrant pain - Periumbilical pain
R10.83 Colic
R10.84 Generalized abdominal pain
R10.9 Unspecified abdominal pain
R11.13 Vomiting of fecal matter
R11.15 Cyclical vomiting syndrome unrelated to migraine
R19.03 - R19.05 Right lower quadrant abdominal swelling, mass and lump - Periumbilic swelling, mass or lump
R19.07 Generalized intra-abdominal and pelvic swelling, mass and lump
R19.09 Other intra-abdominal and pelvic swelling, mass and lump
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
S36.510A Primary blast injury of ascending [right] colon, initial encounter
S36.511A Primary blast injury of transverse colon, initial encounter
S36.512A Primary blast injury of descending [left] colon, initial encounter
S36.513A Primary blast injury of sigmoid colon, initial encounter
S36.518A Primary blast injury of other part of colon, initial encounter
S36.519A Primary blast injury of unspecified part of colon, initial encounter
S36.520A Contusion of ascending [right] colon, initial encounter
S36.521A Contusion of transverse colon, initial encounter
S36.522A Contusion of descending [left] colon, initial encounter
S36.523A Contusion of sigmoid colon, initial encounter
S36.528A Contusion of other part of colon, initial encounter
S36.529A Contusion of unspecified part of colon, initial encounter
S36.530A Laceration of ascending [right] colon, initial encounter
S36.531A Laceration of transverse colon, initial encounter
S36.532A Laceration of descending [left] colon, initial encounter
S36.533A Laceration of sigmoid colon, initial encounter
S36.538A Laceration of other part of colon, initial encounter
S36.539A Laceration of unspecified part of colon, initial encounter
S36.61XA Primary blast injury of rectum, initial encounter
S36.62XA Contusion of rectum, initial encounter
S36.63XA Laceration of rectum, initial encounter
T18.3XXA Foreign body in small intestine, initial encounter
T18.4XXA Foreign body in colon, initial encounter
T18.5XXA Foreign body in anus and rectum, initial encounter
T18.8XXA Foreign body in other parts of alimentary tract, initial encounter
T18.9XXA Foreign body of alimentary tract, part unspecified, initial encounter
T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter
T82.828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter
T82.848A Pain due to vascular prosthetic devices, implants and grafts, initial encounter
T82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter
T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.9XXA Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter
T85.611A Breakdown (mechanical) of intraperitoneal dialysis catheter, initial encounter
T85.621A Displacement of intraperitoneal dialysis catheter, initial encounter
T85.631A Leakage of intraperitoneal dialysis catheter, initial encounter
Z03.821 Encounter for observation for suspected ingested foreign body ruled out
Z03.823 Encounter for observation for suspected inserted (injected) foreign body ruled out
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
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
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z85.05 Personal history of malignant neoplasm of liver
Z86.010 Personal history of colonic polyps
Z87.19 Personal history of other diseases of the digestive system

Group 2

(1 Code)
Group 2 Paragraph

Group 2A

The following ICD-10-CM codes must be used in pairs, i.e., one primary diagnosis and one secondary diagnosis.


Primary Diagnosis:

Group 2 Codes
Code Description
S31.609A Unspecified open wound of abdominal wall, unspecified quadrant with penetration into peritoneal cavity, initial encounter

Group 3

(13 Codes)
Group 3 Paragraph

Group 2B
Secondary diagnosis:

Group 3 Codes
Code Description
S36.500A - S36.503A Unspecified injury of ascending [right] colon, initial encounter - Unspecified injury of sigmoid colon, initial encounter
S36.508A Unspecified injury of other part of colon, initial encounter
S36.509A Unspecified injury of unspecified part of colon, initial encounter
S36.60XA Unspecified injury of rectum, initial encounter
N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
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.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.


Code Description
0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
0450 Emergency Room - General Classification
0490 Ambulatory Surgical Care - General Classification
0510 Clinic - General Classification
0514 Clinic - OB-GYN Clinic
0515 Clinic - Pediatric Clinic
0516 Clinic - Urgent Care Clinic
0517 Clinic - Family Practice Clinic
0519 Clinic - Other Clinic
0750 Gastro-Intestinal (GI) Services - General Classification
0760 Specialty Services - General Classification
0960 Professional Fees - General Classification
0969 Professional Fees - Other Professional Fee
0972 Professional Fees - Radiology - Diagnostic
0973 Professional Fees - Radiology - Therapeutic
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/26/2023 R10

R9

Revision Effective: 01/26/2023

Revision Explanation: Annual Review, no changes were made.

02/03/2022 R9

R8

Revision Effective: 10/01/2022

Revision Explanation: Q85.8 was deleted and Q85.81, Q85.82, Q85.83, and Q85.89 was added 

02/03/2022 R8

R7

Revision Effective: 02/03/2022

Revision Explanation: Annual Review, no changes were made.

02/04/2021 R7

R6

Revision Effective: 02/04/2021

Revision Explanation: Annual Review, no changes were made.

10/01/2020 R6

R5
Revision Effective: 10/01/2020
Revision Explanation: Added new codes from annual ICD-10 review Z03.821 and Z03.823.

10/01/2020 R5

R4
Revision Effective: 10/01/2020
Revision Explanation: During the annual ICD-10 update K59.8 was deleted in group 1 and replaced with K59.81.

10/01/2019 R4


Revision Effective: N/A

Revision Explanation: Annual Review, no changes made.

10/01/2019 R3

R3

Revision Effective: 10/01/2019

Revision Explanation: New code R11.15 was added to ICD-10 group 1 from the annual ICD-10 update.

09/19/2019 R2

R2

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

04/04/2019 R1

Revision Effective date: 4-4-2019

Revision Explanation: Correction was made to Group 1 paragraph

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L34005 - Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related National Coverage Documents
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SAD Process URL 1
N/A
SAD Process URL 2
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Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/25/2024 02/01/2024 - N/A Currently in Effect View
12/11/2023 12/21/2023 - 01/31/2024 Superseded View
11/08/2023 11/16/2023 - 12/20/2023 Superseded View
01/20/2023 01/26/2023 - 11/15/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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