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Contractor's Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LMRP Database ID Number

L781

LMRP Title

Diagnostic and Therapeutic Colonoscopy

Contractor's Policy Number

00-07-R6

AMA CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply.

CMS National Coverage Policy

• Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
• Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
• Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

Oversight Region

Region III

CMS Consortium

Northeast

Original Policy Effective Date

06/26/2000

Entire Policy Ending Date

Revision Effective Date

01/01/2004

Revision Ending Date

12/31/2003

LMRP Abstract

Colonoscopy is a visual examination of the lining of the large intestine with a flexible endoscope. The colonoscope is inserted anally or through the stoma and is advanced through the large intestine under direct vision, using the scope’s viewing system.

Indications and Limitations of Coverage and/or Medical Necessity

The following are Medicare covered indications:

• Evaluation of an abnormality on barium enema that is likely to be clinically significant, such as a filling defect, stricture or polyps,
• Evaluation of an unexplained gastrointestinal bleeding:
• Hematochezia not thought to be from rectum or perianal source,
• Melena of unknown origin, or
• Presence of fecal occult blood.
• Unexplained iron deficiency anemia,
• Evaluation of abdominal pain suggestive of colonic origin,
• Evaluation of symptoms of colonic obstruction,
• Surveillance of colonic neoplasia
• Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp,
• Follow-up in one year, then three- to five- year intervals following resection of colorectal cancer or neoplastic polyp, or in less than one year if polyp is large or sessile or has carcinoma in situ,
• Inpatients with Crohn’s colitis and chronic ulcerative colitis: colonoscopy every one or two years with multiple biopsies for detection of cancer and dysplasia in patients with
• Pancolitis of greater than seven (7) years duration, or;
• Left-sided colitis of over 15 years duration (no surveillance needed for disease limited to rectosigmoid).
• Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management,
• Clinically significant diarrhea or recent change in bowel habits of unexplained origin. Generally, diarrhea is a mild, self-limited condition that does not require colonoscopic evaluation. However, unexplained diarrhea that is severe or chronic would justify the use of this test.
• Preoperative endoscopic marking for surgical location and intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source),
• Evaluation of acute colonic ischemia/ischemic bowel disease,
• Evaluation of patient with Streptococcus Bovis endocarditis,
• Treatment of bleeding from such lesions as vascular anomalies, ulceration, and neoplasia,
• Removal of foreign body,
• Excision of colonic polyps, decompression of megacolon,
• Treatment of sigmoid volvulus, or;
• Treatment stenotic lesions.

Colonoscopy is generally not covered for treating the following symptoms or diagnoses. The patient’s medical records must have additional documentation indicating the medical necessity of the procedure for Medicare’s review as needed.

• Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions, in which colonoscopy may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy,
• Acute limited diarrhea,
• Hemorrhoids,
• Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management,
• Routine follow-up of inflammatory dowel disease (except for cancer surveillance in chronic ulcerative colitis and Crohn’s colitis,
• Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease,
• Upper GI bleeding or melena with demonstrated upper GI source, or;
• Bright red rectal bleeding in patients with a convincing anorectal source on sigmoidoscopy, and no other symptoms suggestive of a more proximal bleeding source.

Colonoscopy is not indicated for:

• Fulminant colitis,
• Possible perforated viscus, and;
• Acute severe diverticulitis.

CPT/HCPCS Section

Surgery/Digestive System

Benefit Category

Diagnostic Services in Outpatient Hospital
Diagnostic Tests (other)

Coverage Topic

Diagnostic tests and x-rays

Type of Bill Code

11X, 18X, 21X (HCPCS not required)

13X, 83X, 85X (HCPCS required)

Revenue Codes

36X, 45X, 49X, 75X

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

44388	©	Colon endoscopy
44389	©	ColonoColonoscopy with biopsy
44390	©	ColonoColonoscopy for foreign body
44391	©	ColonoColonoscopy for bleeding
44392	©	ColonoColonoscopy & polypectomy
44393	©	ColonoColonoscopy & lesion removal
44394	©	ColonoColonoscopy w/snare
44397	©	Colonoscopy w/stent
45355	©	Surgical colonoscopy
45378	©	Diagnostic colonoscopy
45379	©	Colonoscopy w/fb removal
45380	©	Colonoscopy and biopsy
45381	©	Colonoscope, submucous inj
45382	©	Colonoscopy/control bleeding
45383	©	Lesion removal colonoscopy
45384	©	Lesion remove colonoscopy
45385	©	Lesion removal colonoscopy
45386	©	Colonoscope dilate stricture
45387	©	Colonoscopy

© CPT American Medical Association

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

Covered for:

006.9	Amebiasis, unspecified
009.1-009.3	Infectious colitis, enteritis, and gastroenteritis, infectious diarrhea and diarrhea of
	presumed infectious origin
014.02-014.06	Tuberculous peritonitis
014.82-014.86
153.0-153.9	Malignant neoplasm of hepatic flexure
154.0-154.3	Malignant neoplasm of rectum, rectosigmoid junction and anus
154.8	Malignant neoplasm of other gastrointestinal site
196.2	Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
197.5	Secondary malignant neoplasm of large intestine and rectum
197.7	Secondary malignant neoplasm of liver, specified as secondary
211.3	Benign neoplasm of colon
211.4	Benign neoplasm of rectum and anal canal
230.3-230.5	Carcinoma in situ of colon, rectum and anal canal
230.6	Carcinoma in situ of anus, unspecified
235.2	Neoplasm of uncertain behavior of stomach, intestine, and rectum
235.5	Neoplasm of uncertain behavior of other and unspecified digestive organs
280.0	Iron deficiency anemia secondary to blood loss (chronic)
280.9	Iron deficiency anemia, unspecified
421.0	Acute and subacute bacterial endocarditis
448.0	Hereditary hemorrhagic telangiectasia
555.0-555.2	Regional enteritis
555.9
556.0-556.6	Ulcerative colitis
556.8-556.9	Other and unspecified ulcerative colitis
557.0-557.1	Acute and chronic vascular insufficiency of intestine
557.9	Unspecified vascular insufficiency of intestine
558.1-558.2	Gastroenteritis and colitis due to radiation and toxic gastroenteritis and colitis
	due to radiation
558.3	Allergic gastroenteritis and colitis
558.9	Other and unspecified non-infectious gastroenteritis and colitis
560.0-560.2	Intestinal obstruction without mention of hernia
560.81	Intestinal or peritoneal adhesions with obstruction (post-operative) (post infection)
560.89	Other specified intestinal obstruction
560.9	Unspecified intestinal obstruction
562.10-562.13	Diverticulitis of colon
564.4-564.5	Other post-operative functional disorders
564.81	Neurogenic bowel
564.89	Other functional disorders of intestine
	Note: Use this code for atony of colon.
569.81-569.85	Other specified disorder of intestine
569.86	Dieulafoy lesion (hemorrhagic) of intestine
569.89
578.1	Blood in stool
578.9	Hemorrhage of gastrointestinal tract, unspecified
596.1	Intestinovesical fistula
759.6	Other hamartoses, not elsewhere classified
	Note: Use this code for Peutz-Jeghers syndrome, Sturge-Weber
	(-Dimitri) syndrome, and von Hippel-Lindau syndrome
787.91	Diarrhea
789.00-789.07	Abdominal pain
789.09
	Note: Use these codes to indicate colonic pain or abdominal pain of suspected
	colonic origin.
789.30-789.34	Abdominal or pelvic swelling, mass, or lump
792.1	Non-specific abnormal findings in other body substances, stool contents
793.4	Non-specific abnormal findings on radiological and other examination of
	gastrointestinal tract
936	Foreign body in intestine and colon
V10.00	Personal history of malignant neoplasm, gastrointestinal tract unspecified
V10.05	Personal history of malignant neoplasm, large intestine
V10.06	Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus
V10.07	Personal history of malignant neoplasm, liver
V12.70	Personal history of unspecified digestive disease
V12.72	Personal history of colonic polyps

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

Any diagnosis codes not listed in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Diagnoses that DO NOT Support Medical Necessity

Conditions not listed in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Reasons for Denial

• The service does not follow the guidelines of this policy.
• The medical record does not verify that the service described by the HCPCS code was provided.
• Screening tests in the absence of signs, symptoms, or complaints are denied under §1862 (a) (7) of the Social Security Act.
• This service will not be covered in any place of service not identified under “Indications and Limitations of Coverage.”
• Lack of supporting documentation in the medical record to reflect the medical necessity for the performance of this study will result in denial of the service.

Non-covered ICD-9 Codes

All diagnoses codes not listed in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Non-covered Diagnoses

N/A

Coding Guidelines

• To report this service, use the appropriate HCPCS code.
• Diagnosis (es) must be present on any claim submitted, and must be coded to the highest level of specificity.
• An incomplete colonoscopy is the inability to examine proximal to the splenic flexure. Modifier -73 or -74 should be used when a colonoscopy is performed in an outpatient hospital or ambulatory surgery center setting and is terminated prior to completion of the procedure. Incomplete colonoscopies should be billed as HCPCS code 45378 using either modifier -73 or -74.

Documentation Requirements

• Documentation supporting the medical necessity and the frequency for this procedure should be legible, maintained in the patient’s medical record, and available to Medicare upon request.
• To report these services, use the appropriate HCPCS code.
• An appropriate diagnosis code should be submitted on the claim. The patient’s medical record should indicate the signs/symptoms supporting the diagnosis and functional impairment.
• Infectious colitis is an acceptable indication in its general form. Further specificity in ICD-9-CM coding is not needed, but the clinical necessity of doing colonoscopy in these instances should be documented and maintained in the patient’s medical records.

Utilization Guidelines

Other Comments

This policy does not address or apply to CMS national policy on colorectal cancer screening, which became effective for services on or after January 1, 1998. Please refer to the Intermediary News, December 1997 and June 1998 issues for a description of Medicare coverage for colorectal cancer screening.

Financial Responsibility:

Provider Liable

The provider of the service or the ordering physician must have notified the patient in writing, prior to the service, and obtained a signature verifying Advance Beneficiary Notice. Without prior notice, services denied as not medically necessary cannot be billed to the beneficiary. The provider is liable.

Beneficiary Liable

If there is clear evidence that the beneficiary was issued and signed an Advanced Beneficiary Notice (ABN) prior to the service, the liability rests with the beneficiary. Claims for dates of service prior to January 1, 2003 should contain the condition code 20 and occurrence code 32, with date to signify that an ABN was issued to the beneficiary. Absence of these codes will result in a provider liable determination

Claims for dates of service beginning January 1, 2003 should contain the occurrence code 32 with date to signify that an ABN was issued to the beneficiary. Absence of this code will result in a provider liable determination.

Reference: PM AB-02-168, CR 2415

Sources of Information and Basis for Decision

• TrailBlazer Health Enterprises, LLC, Medicare Part B Newsletter No. 00-001, October 11, 1999
• Maryland Medicare Part A Local Medical Review Policy September 12, 1996
• Coverage Issues Manual 35-59

Advisory Committee Notes

Start Date of Comment Period

04/05/2000

End Date of Comment Period

Start Date of Notice Period

05/26/2000

Revision History Number

00-07-R6

Revision History

Number	Date	Change
00-07-R6	1/1/2004	Addition of ICD-9 code 787.91. Updated format.
00-07-R5	10/01/2003	Spelling errors corrected.
		HCPCS descriptors changed from long to short descriptors.
00-07-R4	01/01/2003	Annual update of CPT/HCPCS codes. Addition of 45381 and 45386.
00-07-R3	10/01/2002	Annual update of ICD-9 codes for 2003. See bulletin on website for specifics.
00-07-R2	01/01/2001	Addition of new HCPCS codes, 44397 and 45387 for calendar
		year 2001.
00-07-R1	11/17/2000	Correction of ICD-9-CM code 213.3 to 213.31. Limited coverage
		expanded to include 558.3 to maintain consistency in policies between
		intermediary and carrier.

Disclaimer Specialty Name

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

Advisory Committee Meeting Date:

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.