- 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:
- 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).
- 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.
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
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.
Ct colonography, w/o dye
Ct colonography, w/dye
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:
Ill-defined intestinal infections
Tuberculosis of intestines, peritoneum, and mesenteric glands - Other
Malignant neoplasm of colon
Malignant neoplasm of rectum, rectosigmoid junction, and anus
Malignant neoplasm of rectum, rectosigmoid junction, and anus, other
Secondary and unspecified malignant neoplasm of intra abdominal lymph nodes
Secondary malignant neoplasm of large intestine and rectum
Secondary malignant neoplasm of liver, specified as secondary
Malignant neoplasm without specification of site
Benign neoplasm of other parts of digestive system
Carcinoma in situ of digestive organs
Neoplasm of uncertain behavior of stomach, intestine and rectum
Neoplasm of uncertain behavior of other and unspecified digestive organs
Iron deficiency anemia secondary to blood loss (chronic)
Iron deficiency anemia, unspecified
Acute and subacute bacterial endocarditis
Hereditary hemorrhagic telangiectasia
Regional enteritis, unspecified site
Vascular insufficiency of intestine
Unspecified vascular insufficiency of intestine
Other and unspecified non-infectious gastroenteritis and colitis
Eosinophilic gastroenteritis and colitis
Other and unspecified non-infectious gastroenteritis and colitis
Intestinal obstruction without mention of hernia
Intestinal or peritoneal adhesions with obstruction (post-operative) (post-infection)
Other specified intestinal obstruction
Unspecified intestinal obstruction
Diverticula of intestine, colon
Functional digestive disorders, not elsewhere classified
Megacolon, other than Hirschsprung’s
Other functional disorders of intestine
Note: Use 564.89 for atony of colon.
Anal and rectal polyp
Other disorders of intestine
Other complications of intestinal pouch
Other specified disorders of intestine
Other disorders of intestine
Blood in stool
Hemorrhage of gastrointestinal tract, unspecified
Other hamartoses, not elsewhere classified
Note: Use 759.6 for Peutz-Jeghers syndrome, Sturge-Weber (Dimitri) syndrome and von Hippel Lindau syndrome.
Abdominal pain, other specified site
Note: Use 789.00-789.07 and 789.09 to indicate colonic pain or abdominal pain of suspected colonic origin.
Abdominal or pelvic swelling, mass or lump
Non-specific abnormal findings in other body substances, stool contents
Nonspecific (abnormal) findings on radiological and other examination of gastrointestinal tract
Foreign body in intestine and colon
Personal history of malignant neoplasm, gastrointestinal tract, unspecified
Personal history of malignant neoplasm, gastrointestinal tract
Personal history of unspecified digestive disease
Personal history of colonic polyps
Mechanical and motor problems with internal organs
Covered for secondary diagnoses:
Other and unspecified coagulation defects
Atresia and stenosis of large intestine, rectum, and anal canal
Digestive system complications
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.
Other specified conditions influencing health status
Note: Use V49.89 for increased sedation risk.
Long-term (current) use of anticoagulants
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
ICD-9-CM Codes That DO NOT Support Medical Necessity
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 supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.