- Those patients in whom a standard (fiberoptic, video) colonoscopy of the entire colon is incomplete due to an inability to pass the colonoscope proximally. Failure to advance the colonoscope may be secondary to an obstructing neoplasm, spasm, redundant colon, diverticulitis, extrinsic compression or aberrant anatomy/scarring from prior surgery.
- Preoperative cancer staging and determination of colonic wall invasion.
- CT colonography may also be medically reasonable and necessary for those patients in whom a standard colonoscopy is contraindicated. The following are considered contraindications to standard colonoscopy, and therefore covered indications for CT colonography:
- Coagulopathy.
- Lifetime anticoagulation or long-term anticoagulation therapy with significantly increased patient risk if discontinued.
- Increased sedation risk (e.g., COPD, previous anesthesia adverse reaction).
- Diverticular disease with acute diverticulitis or severe chronic diverticulosis where colonoscopy is contraindicated or would subject the patient to increased risk of perforation.
- Complications from previous standard colonoscopy.
- Obstruction (e.g., cancer, diverticulitis, radiation scarring, adhesions).
Limitations
- CT colonography is not reimbursable when used for screening (74263) 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 reimbursable when used as an alternative to standard diagnostic colonoscopy, except as noted above, since current literature does not yet support the relative effectiveness of this modality.
- CT colonography would not be expected to be performed when there is either a known or strongly expected need for biopsy.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 71X, 73X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
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 policy 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 policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
036X, 040X, 045X, 051X, 052X, 075X, 076X, 096X, 0972, 0973, 0982, 0988
CPT/HCPCS Codes
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Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and CMS require the use of short CPT descriptors in policies published on the Web.
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74261©
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Ct colonography, w/o dye
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74262©
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Ct colonography, w/dye
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ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered primary and a covered secondary diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following dual diagnosis limited coverage requirement for CPT/HCPCS codes 74261 and 74262.
Covered for primary diagnoses:
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006.9
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Amebiasis, unspecified
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009.1–009.3
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Ill-defined intestinal infections
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014.02–014.06
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Tuberculous peritonitis
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014.82–014.86
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Tuberculosis of intestines, peritoneum, and mesenteric glands – Other
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153.0–153.9
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Malignant neoplasm of colon
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154.0–154.3
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Malignant neoplasm of rectum, rectosigmoid junction, and anus
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154.8
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Malignant neoplasm of rectum, rectosigmoid junction, and anus, other
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196.2
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Secondary and unspecified malignant neoplasm of intra abdominal lymph nodes
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197.5
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Secondary malignant neoplasm of large intestine and rectum
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197.7
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Secondary malignant neoplasm of liver, specified as secondary
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199.0–199.2
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Malignant neoplasm without specification of site
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211.3–211.4
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Benign neoplasm of other parts of digestive system
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230.3–230.6
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Carcinoma in situ of digestive organs
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235.2
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Neoplasm of uncertain behavior of stomach, intestine and rectum
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235.5
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Neoplasm of uncertain behavior of other and unspecified digestive organs
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280.0
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Iron deficiency anemia secondary to blood loss (chronic)
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280.9
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Iron deficiency anemia, unspecified
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421.0
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Acute and subacute bacterial endocarditis
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448.0
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Hereditary hemorrhagic telangiectasia
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555.0–555.2
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Regional enteritis
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555.9
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Regional enteritis, unspecified site
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556.0–556.6
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Ulcerative colitis
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556.8–556.9
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Ulcerative colitis
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557.0–557.1
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Vascular insufficiency of intestine
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557.9
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Unspecified vascular insufficiency of intestine
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558.1–558.3
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Other and unspecified non-infectious gastroenteritis and colitis
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558.41-558.42
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Eosinophilic gastroenteritis and colitis
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558.9
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Other and unspecified non-infectious gastroenteritis and colitis
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560.0–560.2
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Intestinal obstruction without mention of hernia
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560.81
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Intestinal or peritoneal adhesions with obstruction (post-operative) (post-infection)
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560.89
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Other specified intestinal obstruction
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560.9
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Unspecified intestinal obstruction
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562.10–562.13
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Diverticula of intestine, colon
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564.00
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Constipation, unspecified
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564.4–564.5
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Functional digestive disorders, not elsewhere classified
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564.7
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Megacolon, other than Hirschsprung’s
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564.81
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Neurogenic bowel
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564.89*
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Other functional disorders of intestine
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Note: Use 564.89 for atony of colon.
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569.0
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Anal and rectal polyp
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569.2–569.3
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Other disorders of intestine
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569.71
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Pouchitis
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569.79
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Other complications of intestinal pouch
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569.81–569.87
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Other specified disorders of intestine
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569.89
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Other disorders of intestine
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578.1
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Blood in stool
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578.9
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Hemorrhage of gastrointestinal tract, unspecified
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596.1
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Intestinovesical fistula
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759.6*
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Other hamartoses, not elsewhere classified
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Note: Use 759.6 for Peutz-Jeghers syndrome, Sturge-Weber (Dimitri) syndrome and von Hippel Lindau syndrome.
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|
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787.91
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Diarrhea
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789.00–789.07*
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Abdominal pain
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789.09*
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Abdominal pain, other specified site
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Note: Use 789.00-789.07 and 789.09 to indicate colonic pain or abdominal pain of suspected colonic origin.
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|
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789.30–789.37
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Abdominal or pelvic swelling, mass or lump
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792.1
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Non-specific abnormal findings in other body substances, stool contents
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793.4
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Nonspecific (abnormal) findings on radiological and other examination of gastrointestinal tract
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936
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Foreign body in intestine and colon
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V10.00
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Personal history of malignant neoplasm, gastrointestinal tract, unspecified
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V10.05–V10.07
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Personal history of malignant neoplasm, gastrointestinal tract
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V12.70
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Personal history of unspecified digestive disease
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V12.72
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Personal history of colonic polyps
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V47.1
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Mechanical and motor problems with internal organs
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Covered for secondary diagnoses:
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286.0–286.7
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Coagulation defects
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286.9
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Other and unspecified coagulation defects
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751.2
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Atresia and stenosis of large intestine, rectum, and anal canal
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997.4*
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Digestive system complications
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Note: Use 997.4 for diverticular disease with increased risk of perforation, complications from previous standard colonoscopy and other sources of obstruction (see 751.2 above) involving cancer, diverticulitis, radiation scarring, adhesions, etc.
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V49.89*
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Other specified conditions influencing health status
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Note: Use V49.89 for increased sedation risk.
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V58.61
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Long-term (current) use of anticoagulants
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Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
