SUPERSEDED Local Coverage Determination (LCD)

Diagnostic and Therapeutic Colonoscopy

L36868

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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.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L36868
Original ICD-9 LCD ID
Not Applicable
LCD Title
Diagnostic and Therapeutic Colonoscopy
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL36868
Original Effective Date
For services performed on or after 07/17/2017
Revision Effective Date
For services performed on or after 10/01/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
06/01/2017
Notice Period End Date
07/16/2017
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.

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

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Issue

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

CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A) states that no Medicare payment shall be made for items or services that “are not 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, §1862(a)(7) and 42 Code of Federal Regulations, §411.15 et seq. exclude routine physical examinations.

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

Title XVIII of the Social Security Act, §1862(a)(1)(H) and Balanced Budget Act ‘97’, Chapter V, Subtitle B, §4104 provides coverage for colorectal cancer screening tests.

CMS Manual System, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, §30.1B, addresses incomplete colonoscopies.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Colonoscopy is a visual examination of the lining of the large intestine using a rigid or flexible video or fiberoptic endoscope. The procedure includes inspection of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. A colonoscopy, by definition, must examine the colon proximal to the splenic flexure. The colonoscope is inserted via the anus or stoma, and then advanced under direct vision or video image. A rigid sigmoidoscope may be used for an intraoperative transcolotomy approach.

A colonoscopy requires the use of a flexible fiberoptic instrument that has the potential to examine the entire colon, and must potentially reach the entire colon (i.e. the cecum) when inserted through the anus.

Do not report a colonoscopy procedure code for an endoscopy performed with a sigmoidoscope on a patient with a normal length colon, even if the sigmoidoscope reaches proximal to the splenic flexure. A sigmoidoscope (an endoscope typically 65 centimeters in length) may be used for a colonoscopy only if the bowel is sufficiently short so that the entire colon may be examined and such should be clearly documented in the clinical record.

Coverage for screening colonoscopy and other modalities for colorectal cancer is covered by CMS national policy NCD Chapter 1 Section 210.3 and in the Internet Only Manual 100-04, Chapter 18 Section 60.

A diagnostic colonoscopy is indicated for the following:

  • Evaluation of an abnormality discovered by a radiology examination wherein the findings of the study are consistent with a colonic lesion that is likely to be clinically significant,
  • An abnormal oncology colorectal screening or stool based DNA test as described in the CMS Colorectal Cancer screening Preventive Services requirements,
  • Evaluation of unexplained gastrointestinal bleeding:
      • Hematochezia that is not from the rectum or a perianal source,

      • Melena of unknown origin after an upper GI source has been ruled out or when clinical findings indicate that a lower GI source may also be present,

      • Presence of fecal occult blood, or

    • Unexplained iron deficiency anemia.
  • Clinically significant diarrhea of unexplained origin, after other appropriate workup,
  • Evaluation of acute colonic ischemia/ischemic bowel disease,
  • Evaluation of patients with streptococcus bovis endocarditis when a source is determined to likely to be of colonic origin (e.g. streptococcus bovis),
  • Clinical suspicion of inflammatory bowel disease which may be manifested by abdominal pain, fever, diarrhea, bloody diarrhea, elevated erythrocyte sedimentation rate or other pertinent findings,
  • Known chronic inflammatory bowel disease of the colon when a more precise determination of the extent of disease will influence clinical management,
  • Surveillance of selected patients with Crohn’s colitis, or chronic ulcerative colitis for the purpose of ruling out colorectal cancer is considered high risk screening and should follow the requirements set forth in the CMS Internet Only Manual 100-04 Chapter 18 Section 60
  • Surveillance of colonic neoplasia:
      • Evaluation of the entire colon for a cancer with polyps noted on an earlier colonoscopy in accordance with the established national guidelines.

    • This includes patients with known polyps from a previous colonoscopy or imaging study who have a known genetic predisposition for colon cancer.
  • Intraoperative identification of the site of a lesion for findings that are suspected but that cannot be confirmed/detected by palpation or gross inspection at surgery.


Diagnostic colonoscopy is not covered for evaluation of the following:

    • Chronic, stable irritable bowel syndrome,
    • Acute limited diarrhea,
    • Hemorrhoids,
    • Metastatic adenocarcinoma of unknown primary site when a colonic origin is strongly suspected based on history and physical and imaging findings or biopsy reports,
    • Routine follow-up of inflammatory bowel disease (except as indicated above in this section),
    • Routine examination of the colon in patients about to undergo elective abdominal surgery for noncolonic disease,
    • Upper GI bleeding or melena with a demonstrated upper GI source and absence of findings suggestive of a lower GI bleeding site,
    • Bright red rectal bleeding in patients with a convincing anorectal source via direct examination, anoscopy, or sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source,
  • Patients with a family history of colon cancer without a personal history of symptoms. These patients may be covered by the CMS Colorectal Screening coverage.


A therapeutic colonoscopy is indicated for:

    • Treatment of bleeding from such lesions as vascular anomalies, ulceration, and neoplasia,
    • Balloon dilation of a stenotic lesion,
    • Decompression of a sigmoid volvulus and/or an acute non-toxic megacolon or pseudo-obstruction associated with Ogilvie’s Syndrome
    • Removal of foreign body,
    • Excision of colonic polyps.
  • Repair of a perforation when it is expected that such repair will most likely avoid further surgical intervention and further surgical intervention is not needed (for example to drain an abscess at which time the perforation could be corrected by the surgeon)


Colonoscopy is contraindicated if the patient has:

    • Fulminant colitis,
    • Acute severe diverticulitis, or
  • Suspected perforated viscus. A therapeutic colonoscopy by a trained endoscopist capable of repairing a perforation site may be allowed when the clinical findings and imaging studies strongly indicate that a perforation has occurred and the suspected site of the perforation allows for endoscopic repair.


The requirements for coverage have not been met if:

    • Only a sigmoidoscope is used.
    • An office based colonoscopy is not validated with the appropriate equipment information.
  • Chronic abdominal pain unresponsive to medical therapy is used to justify the service, but lacks appropriate clinical documentation.
Summary of Evidence

NA

Analysis of Evidence (Rationale for Determination)

NA

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

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.

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

Group 1

(25 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)
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
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
45393 COLONOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(260 Codes)
Group 1 Paragraph:

N/A

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
A06.0 Acute amebic dysentery
A06.1 Chronic intestinal amebiasis
A06.2 Amebic nondysenteric colitis
A06.9 Amebiasis, unspecified
A18.31 Tuberculous peritonitis
A18.32 Tuberculous enteritis
A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
A41.4 Sepsis due to anaerobes
A41.50 Gram-negative sepsis, unspecified
A41.51 Sepsis due to Escherichia coli [E. coli]
A41.52 Sepsis due to Pseudomonas
A41.53 Sepsis due to Serratia
A41.59 Other Gram-negative sepsis
A41.81 Sepsis due to Enterococcus
A41.89 Other specified sepsis
A42.7 Actinomycotic sepsis
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
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
C45.1 Mesothelioma of peritoneum
C46.4 Kaposi's sarcoma of gastrointestinal sites
C48.1 Malignant neoplasm of specified parts of peritoneum
C48.2 Malignant neoplasm of peritoneum, unspecified
C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C49.4 Malignant neoplasm of connective and soft tissue of abdomen
C49.A4 Gastrointestinal stromal tumor of large intestine
C49.A9 Gastrointestinal stromal tumor of other sites
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
C76.2 Malignant neoplasm of abdomen
C76.3 Malignant neoplasm of pelvis
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
C80.2 Malignant neoplasm associated with transplanted organ
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
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
D37.3 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
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D50.9 Iron deficiency anemia, unspecified
E34.0 Carcinoid syndrome
E44.0 Moderate protein-calorie malnutrition
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
K50.10 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
K50.80 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
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
K51.20 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
K51.30 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
K51.40 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
K51.50 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
K51.80 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
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
K52.81 Eosinophilic gastritis or gastroenteritis
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
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
K55.1 Chronic vascular disorders of intestine
K55.20 Angiodysplasia of colon without hemorrhage
K55.21 Angiodysplasia of colon with hemorrhage
K55.8 Other vascular disorders of intestine
K56.0 Paralytic ileus
K56.1 Intussusception
K56.2 Volvulus
K56.3 Gallstone ileus
K56.41 Fecal impaction
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
K56.690 Other partial intestinal obstruction
K56.691 Other complete intestinal obstruction
K56.699 Other intestinal obstruction unspecified as to partial versus complete obstruction
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
K59.1 Functional diarrhea
K59.2 Neurogenic bowel, not elsewhere classified
K59.8 Other specified functional intestinal disorders
K62.0 Anal polyp
K62.1 Rectal polyp
K62.2 Anal prolapse
K62.3 Rectal prolapse
K62.4 Stenosis of anus and rectum
K62.5 Hemorrhage of anus and rectum
K62.6 Ulcer of anus and rectum
K62.7 Radiation proctitis
K62.81 Anal sphincter tear (healed) (nontraumatic) (old)
K62.89 Other specified diseases 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
K63.89 Other specified diseases of intestine
K64.0 First degree hemorrhoids
K64.1 Second degree hemorrhoids
K64.2 Third degree hemorrhoids
K64.3 Fourth degree hemorrhoids
K64.4 Residual hemorrhoidal skin tags
K64.5 Perianal venous thrombosis
K64.8 Other hemorrhoids
K64.9 Unspecified hemorrhoids
K90.1 Tropical sprue
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
L83 Acanthosis nigricans
Q42.8 Congenital absence, atresia and stenosis of other parts of large intestine
Q85.8 Other phakomatoses, not elsewhere classified
R10.0 Acute abdomen
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.2 Pelvic and perineal pain
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.84 Generalized abdominal pain
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
R71.0 Precipitous drop in hematocrit
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
Z85.020 Personal history of malignant carcinoid tumor 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
Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung
Z85.230 Personal history of malignant carcinoid tumor of thymus
Z85.520 Personal history of malignant carcinoid tumor of kidney
Z85.821 Personal history of Merkel cell carcinoma
Z86.004 Personal history of in-situ neoplasm of other and unspecified digestive organs
Z86.010 Personal history of colonic polyps
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

N/A

Additional ICD-10 Information

N/A

General Information

Associated Information

Documentation Requirement
Supportive clinical documentation evidencing the condition and treatment is expected to be documented in the clinical notes or procedure note and be made available upon request from the MAC or other authorized CMS auditor.

Medical records need not be submitted with the claim unless modifier 22 is used; however, they must be furnished to Medicare upon request.

The medical records must support the medical reasonableness, necessity, and frequency of each diagnostic service supplied.

The medical record must substantiate the diagnosis listed on the claim form.

The colonoscopy report must describe the following:

    • The maximum depth of penetration;
    • A description of any abnormal findings; and
  • Any procedures performed as the result of such findings (e.g., biopsy).


For a colonoscopy performed in the office (POS 11), the provider shall maintain on file the make, model number, and serial number of the colonoscope and provide this information to the contractor upon request. Payment for a colonoscopy performed in the office is subject to recovery when colonoscope information is not available to the contractor.

The patient’s medical record must be legible and clearly indicate the medical need for the colonoscopy. In addition, the medical record must include the test result and document its impact on treatment.

If the only indication is abdominal pain, ICD-10-CM code R10.0, the documentation must show the chronic nature of the pain, the medical therapy tried, and the response.

An incomplete colonoscopy is defined by CMS in the IOM at 100-4, Chapter 12, Section 30.1.B; Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)

An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

When the colonoscopy procedure is unusual or difficult, modifier 22 (unusual procedural services) may be reported.

The most specific ICD-10-CM code must be chosen and billed to its highest level of specificity. Submit this as the line diagnosis (linked to the procedure) on the claim.

Frequency
Typically, the initial follow-up for colorectal cancer, adenomatous or neoplastic polyps is a colonoscopy in 1 year, then 3-5 year intervals following resection.

Sources of Information
  1. Medical Consultants
  2. Anthem Guidelines for Colonoscopy (Accessed 08/10/2016): The role of endoscopy in the patient with lower GI bleeding; Gastrointestinal Endoscopy 2014 Vol. 79, No. 6, pp 875-885.
  3. C42 CFR Ch IV Section 410.37
  4. Colonoscopy surveillance after colorectal cancer resection: recommendations of the US multi-society task force on colorectal cancer; Gastrointestinal Endoscopy 2016 Vol.83, No. 3, pp 489-498e10.
  5. Colorectal Cancer Screening and Surveillance; American Family Physician January 15, 2015, pp 93-100.
  6. Management of Crohn’s Disease in Adults American Journal of Gastroenterology Practice Guidelines January 6, 2009.
  7. American Society for Gastrointestinal Endoscopy:
  8. Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer GASTROENTEROLOGY 2012;143:844–857.
  9. The role of endoscopy in inflammatory bowel disease; Gastrointestinal Endoscopy 2015 Vol. 81, No. 5, pp 1101-1121e13.
  10. The role of endoscopy in the management of patients with known or suspected colonic obstruction or pseudo-obstruction; Gastrointestinal Endoscopy 2010 Vol. 71, No.4, pp 669-679.
  11. Other contractor’s local medical review policies.


NOTE: Some of the websites used to create this policy may no longer be available.

Bibliography

NA

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/01/2019 R3
 

08/22/2019: 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.

Effective 8/9/19 -In Sources of Information section, #7- American Society for Gastrointestinal Endoscopy: Diagnostic and Therapeutic Procedure had a broken link. The link has been removed. 

Effective 10/01/2019 added ICD-10 code Z86.004 per 2019-2020 ICD-10 Updates.

 

  • Revisions Due To ICD-10-CM Code Changes
  • Other (Broken Hyperlink)
10/01/2017 R2

In Revision History number 2 the added code K56.999 should be K56.699

  • Typographical Error
10/01/2017 R1

08/24/2017: 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.

Effective 10/01/2017 the following ICD-10-CM codes were added per the annual ICD-10-CM updates

  • A04.71
  • A04.72
  • K56.50
  • K56.51
  • K56.52
  • K56.690
  • K56.691
  • K56.999

Effective 10/01/2017 the following ICD-10 codes were deleted from the ICD-10 Codes that Support Medical Necessity field:
A04.7
K56.5
K56.69

  • Revisions Due To CPT/HCPCS Code Changes
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
05/14/2020 10/01/2019 - N/A Currently in Effect View
01/29/2020 10/01/2019 - N/A Superseded View
10/03/2019 10/01/2019 - N/A Superseded View
08/29/2019 10/01/2019 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • 44388
  • 44389
  • 44390
  • 44391
  • 44392
  • 44394
  • 44401
  • 44402
  • 44404
  • 44405
  • 44406
  • 44407
  • 45378
  • 45379
  • 45380
  • 45381
  • 45382
  • 45384
  • 45385
  • 45386
  • 45388
  • 45389
  • 45391
  • 45392
  • 45393
  • Diagnostic
  • Therapeutic
  • Colonoscopy

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