cpt 74261, 74262 - Computed Tomography (CT) Colonography

  • 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
Note:
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.
74261©
Ct colonography, w/o dye
74262©
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:
006.9
Amebiasis, unspecified
009.1–009.3
Ill-defined intestinal infections
014.02–014.06
Tuberculous peritonitis
014.82–014.86
Tuberculosis of intestines, peritoneum, and mesenteric glands - Other
153.0–153.9
Malignant neoplasm of colon
154.0–154.3
Malignant neoplasm of rectum, rectosigmoid junction, and anus
154.8
Malignant neoplasm of rectum, rectosigmoid junction, and anus, other
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
199.0–199.2
Malignant neoplasm without specification of site
211.3–211.4
Benign neoplasm of other parts of digestive system
230.3–230.6
Carcinoma in situ of digestive organs
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
Regional enteritis, unspecified site
556.0–556.6
Ulcerative colitis
556.8–556.9
Ulcerative colitis
557.0–557.1
Vascular insufficiency of intestine
557.9
Unspecified vascular insufficiency of intestine
558.1–558.3
Other and unspecified non-infectious gastroenteritis and colitis
558.41-558.42
Eosinophilic 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
Diverticula of intestine, colon
564.00
Constipation, unspecified
564.4–564.5
Functional digestive disorders, not elsewhere classified
564.7
Megacolon, other than Hirschsprung’s
564.81
Neurogenic bowel
564.89*
Other functional disorders of intestine
Note: Use 564.89 for atony of colon.
569.0
Anal and rectal polyp
569.2–569.3
Other disorders of intestine
569.71
Pouchitis
569.79
Other complications of intestinal pouch
569.81–569.87
Other specified disorders of intestine
569.89
Other disorders of intestine
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 759.6 for Peutz-Jeghers syndrome, Sturge-Weber (Dimitri) syndrome and von Hippel Lindau syndrome.
787.91
Diarrhea
789.00–789.07*
Abdominal pain
789.09*
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.
789.30–789.37
Abdominal or pelvic swelling, mass or lump
792.1
Non-specific abnormal findings in other body substances, stool contents
793.4
Nonspecific (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–V10.07
Personal history of malignant neoplasm, gastrointestinal tract
V12.70
Personal history of unspecified digestive disease
V12.72
Personal history of colonic polyps
V47.1
Mechanical and motor problems with internal organs
Covered for secondary diagnoses:
286.0–286.7
Coagulation defects
286.9
Other and unspecified coagulation defects
751.2
Atresia and stenosis of large intestine, rectum, and anal canal
997.4*
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.
V49.89*
Other specified conditions influencing health status
Note: Use V49.89 for increased sedation risk.
V58.61
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
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.

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