Local Coverage Determination (LCD)

Virtual Colonoscopy (CT Colonography)

L33452

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33452
Original ICD-9 LCD ID
Not Applicable
LCD Title
Virtual Colonoscopy (CT Colonography)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL33452
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/24/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
05/04/2017
Notice Period End Date
06/18/2017
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.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only 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.

Title XVIII of the Social Security Act, §1861(pp) provides coverage for colorectal cancer screening tests.

42 CFR 410.32(a) Ordering Diagnostic Tests

42 CFR 411.15(k)(1) Particular services excluded from coverage

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §210.3, Colorectal Cancer Screening Tests

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Indications

Computed Tomography (CT) colonography, also known as virtual colonoscopy, utilizes helical CT of the abdomen and pelvis along with 2D or 3D reconstruction to visualize the colon lumen. The test requires colonic preparation similar to that required for instrument (e.g., fiberoptic, video) colonoscopy, as well as air or carbon dioxide insufflation to achieve colonic distention.

Virtual colonoscopy is only indicated in those patients in whom a diagnostic or surveillance instrument colonoscopy of the entire colon is incomplete due to an inability to fully pass the colonoscope proximally, and a repeat attempt is not indicated, or in patients with a valid contraindication to the safe performance of an instrument colonoscopy. Incomplete colonoscopy must be due to 1 of the following:

1. An obstructing neoplasm

2. Intrinsic scarring, stricture, aberrant anatomy, or obstruction from prior surgery, radiation, or diverticular disease

3. Extrinsic compression

There are few absolute contraindications to instrument colonoscopy. Relative contraindications do not create medical necessity for using CT colonography as a screening procedure, and the above indications must still be met.

The following relative contraindications to instrument colonoscopy may be indications for CT colonography if well documented in the medical record:

    • Severe coagulopathy
    • Long-term anticoagulation
    • Increased sedation risk (such as from severe chronic obstructive pulmonary disease (COPD) or previous anesthesia adverse reaction)

Limitations

CT colonography is not covered when used for screening, or in the absence of signs or symptoms of disease, regardless of family history or other risk factors for the development of colonic disease.

CT colonography is not covered when used as an alternative to instrument colonoscopy for screening or in the absence of signs or symptoms of disease.

CT colonography is not covered following incomplete colonoscopy if the reason for the colonoscopy is other than one of those described above.

CT colonography is intended for use in pre-operative planning when imaging of the non-visualized colon proximal to the obstruction is necessary in making decisions involving the approach to the patient.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Documentation must be legible, relevant and sufficient to justify the services performed for each date of service billed. This documentation must be made available to the A/B MAC upon request.

1. The results of an incomplete instrument colonoscopy that resulted in the order for the CT colonography (virtual colonoscopy) must be retained in the patient's medical record. Similarly, documentation of the presence and severity of a relative contraindication as justification for a CT colonographic examination must be retained in the medical record.

2. The order/prescription from the referring physician must be retained in the patient's medical record.

Utilization Guidelines

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Sources of Information
N/A
Bibliography

Fenlon HM, McAneny DB, Nunes DP, Clarke PD, Ferrucci JT. Occlusive colon carcinoma: Virtual colonoscopy in the preoperative evaluation of the proximal colon. Radiology. 1999;210(2):423-428.

Gluecker TM, Johnson CD, Harmsen WS, et al. Colorectal cancer screening with CT colonography, colonoscopy, and double-contrast barium enema examination: Prospective assessment of patient perceptions and preferences. Radiology. 2003; 227(2):378-84.

Isenberg GA, Ginsberg GG, Barkun AN, et al. Virtual colonoscopy. Gastrointest Endosc. 2003;57(4):451-454.

Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Med. 2008;359(12):1207-1217.

Laghi A, Iannaccone R, Carbone I, et al. Computed tomographic colonography (virtual colonoscopy): Blinded prospective comparison with conventional colonoscopy for the detection of colorectal neoplasia. Endoscopy. 2002;34(6):441-446.

Laghi A, Iannaccone R, Carbone I, et al. Detection of colorectal lesions with virtual computed tomographic colonography. Am J Surgery. 2002;183(2):124-131.

Macari M, Bini EJ, Xue X, et al. Colorectal neoplasms: Prospective comparison of thin-section low-dose multi-detector row CT colonography and conventional colonoscopy for detection. Radiology. 2002; 224(2):383-392.

Morrin MM, Kruskal JB, Farrell RJ, Goldberg SN, McGee JB, Raptopoulos V. Endoluminal CT colonography after an incomplete endoscopic colonoscopy. AJR. 1999;172(4):913-918.

Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis: Computed tomographic colonography. Ann Intern Med. 2005;142(8):635-650.

Neri E, Giusti P, Battolla L, et al. Colorectal cancer: Role of CT colonography in preoperative evaluation after incomplete colonoscopy. Radiology. 2002;223(3):615-619.

Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349(23):2191-2200.

Pickhardt PJ. Three-dimensional endoluminal CT colonography (virtual colonoscopy): Comparison of three commercially available systems. AJR. 2003;181(6):1599-1606.

Ransohoff DF. Virtual colonoscopy - what it can do vs what it will do. JAMA. 2004;291(14):1772-1774.

Sun CH, Li ZP, Meng QF, Yu SP, Xu DS. Assessment of spiral CT pneumocolon in preoperative colorectal carcinoma. World J Gastroenterol. 2005;11(25):3866-3870.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/24/2019 R11

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Virtual Colonoscopy (CT Colonography) A56772 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
08/01/2019 R10

All coding located in the Coding Information section has been moved into the related Billing and Coding: Virtual Colonoscopy (CT Colonography) A56772 article and removed from the LCD.

All verbiage regarding billing and coding under Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Virtual Colonoscopy (CT Colonography) A56772 article. Formatting was corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
07/18/2019 R9

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. CPT® was inserted throughout the LCD where applicable. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
05/03/2018 R8

Under CMS National Coverage Policy removed the verbiage “due to not being reasonable and necessary” from 42 CFR 411.15(k)(1) and removed all italics from this section. Under Coverage Indications, Limitations and/or Medical Necessity – Indications added “e.g.” in front of the word “fiberoptic” in the first paragraph and changed the acronym “COPD” to “chronic obstructive pulmonary disease” in the third bullet. Under Coverage Indications, Limitations and/or Medical Necessity – Limitations deleted the words “Computed tomographic” and removed the parentheses from the acronym “CT” in the first sentence. Under Bibliography changes were made to citations to reflect AMA citation guidelines. The first citation was deleted. The journal title and page number were corrected and the supplement number was added to first citation listed. Punctuation was corrected throughout the policy.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Typographical Error
02/26/2018 R7 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
10/01/2017 R6

Under ICD-10 Codes That Support Medical Necessity deleted ICD-10 codes K56.5, K56.60 and K56.69 and added K56.50, K56.51, K56.52, K56.600, K56.601, K56.609, K56.690, K56.691, K56.699, K91.30, K91.31 and K91.32. This revision is due to the 2017 Annual ICD-10 Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. 

 

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
06/19/2017 R5 Under CMS National Coverage Policy - revised wording to Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) allows coverage and payment for only 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. Added title to CMS Internet-Only Manual Publication 100-08 Chapter 3 Section 3.4.1.3 ‘Diagnosis Code Requirements’. Under Coverage Indications, Limitations and/or Medical Necessity- revised sentence in first paragraph under Indications “The test requires colonic preparation similar to that required for instrument (fiberoptic, video) colonoscopy, as well as air or carbon dioxide insufflation to achieve colonic distention”. Revised sentence in second paragraph to read “Virtual colonoscopy is only indicated in those patients in whom a diagnostic or surveillance instrument colonoscopy of the entire colon is incomplete due to an inability to fully pass the colonoscope proximally, and a repeat attempt is not indicated, or in patients with a valid contraindication to the safe performance of an instrument colonoscopy”. Fourth paragraph revised to read “The following relative contraindications to instrument colonoscopy may be indications for CT colonography if well documented in the medical record”. Revised first sentence under Limitations to read “CPT 74263 Computed tomographic (CT) colonography (ie, virtual colonoscopy) screening including image post processing is never covered”. Under Sources of Information and Basis for Decision – replaced second source of information with Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Me. 2008; 359:1202-1217.
  • Provider Education/Guidance
  • Typographical Error
10/01/2016 R4 Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes C49.A0, C49.A1, C49.A2, C49.A3, C49.A4, C49.A5, C49.A9, K55.032, K55.039, K55.041, K55.042, K55.049, K55.051, K55.052, K55.059, K55.061, K55.062, K55.069, K59.31 and K59.39.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
06/03/2016 R3 Under CMS National Coverage Policy “SSA” was removed from the first reference. The second reference was corrected from the Social Security Act §1862(a)(1)(H) to the Social Security Act §1861(pp). Part 4 was added to the sixth reference. The abbreviation for chapter was replaced with the full word in references seven and eight. The “s” was removed from the word “Manuals” in the eighth reference. Under Sources of Information and Basis for Decision, the citations were corrected to conform to the American Medical Association citation style. In citation number 2: the letter “B” was added to “Pineau” to complete the author’s name. In citation number 9, the initial “M” was added to the first name of “Morrin” to complete the author’s name. In reference number 11, the author “Goisto”, was corrected to “Giusti”. The spelling of Endoluminal was corrected in citation number 13.
  • Provider Education/Guidance
  • Typographical Error
01/07/2016 R2 Under Coverage, Indications, Limitations and/or Medical Necessity, subheading Indications removed #4 Patient safety. Palmetto GBA is always concerned about patient safety no matter what is done, but this statement was too vague and not really relevant.
  • Provider Education/Guidance
  • Reconsideration Request
10/01/2015 R1 Under CMS National Coverage Policy corrected citation reference CMS Internet-Only Manuals, Pub. 100-03, National Coverage Determinations Manual, Chapter 1, §210.3, Colorectal Cancer Screening Tests instead of 220.3. Added reference citation, CMS Internet-Only Manuals, Pub. 100-08, Medicare Program Integrity Manual, Ch. 3, §3.4.1.3, states each claim submitted "shall include the appropriate diagnosis code (or codes)"...
  • Provider Education/Guidance
  • Typographical Error
  • Other (Added reference citation.)
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
10/14/2019 10/24/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Colonoscopy
  • Virtual Colonoscopy

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