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Local Coverage Determination (LCD)

Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

L34005

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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.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34005
Original ICD-9 LCD ID
Not Applicable
LCD Title
Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 02/01/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

    30.1B Incomplete colonoscopies being billed and paid for using CPT code 45378 with modifier 53


CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

    20.4.6 Payment due to unusual circumstances (Modifiers 22 and 52)


CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 18:

    60.2 Colorectal Cancer Screening HCPCS Codes, Frequency Requirements, and Age Requirements (If Applicable)

 

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

This LCD addresses the colonoscopies that are NOT performed for colorectal cancer screening. Colorectal cancer screening is a separate benefit with specific guidelines.

Proctosigmoidoscopy is the examination of the rectum and sigmoid colon.

Sigmoidoscopy is the examination of the entire rectum, sigmoid colon and may include examination of a portion of the descending colon.

Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. The colonoscope is inserted anally (or through a stoma) and is advanced optimally through the large intestine under direct vision, using the scope's optical system.

Indications:

The following are Medicare-covered indications:

  1. Evaluation of an abnormality discovered on barium enema and/or other imaging technique that is likely to be clinically significant, such as a filling defect or stricture or an inadequate examination;

  2. Evaluation of unexplained gastrointestinal bleeding:
    1. Hematochezia not thought to be from rectum or perianal source
    2. Melena of unknown origin;
    3. Presence of fecal occult blood


  3. Unexplained iron deficiency anemia;

  4. Surveillance of colonic neoplasia. When the patient has a history of colorectal cancer or polyps and is being followed for this indication; 

    1. Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp;
    2. Follow-up in one year after surgery for treatment of colorectal cancer;
      • This patient is identified as being at high-risk for colon cancer and is eligible for continued screening at 24-month intervals. 
    3. Follow-up for removal of neoplastic polyp (follow-up at least three to six months to verify removal of large sessile adenoma [i.e., greater than 2 cm in greatest dimension] after colonoscopic removal);
      • This patient is identified as being at high-risk for colon cancer and is eligible for continued screening at 24-month intervals. 
    4. In patients 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 years duration; or,
      • Left-sided colitis of over 15 years duration (no surveillance needed for disease limited to rectosigmoid);
  5. Chronic inflammatory bowel disease of the colon if a more precise diagnosis or if a determination of the extent of activity of disease will influence immediate management;

  6. Clinically significant diarrhea of unexplained origin with additional findings (e.g., with weight loss or negative stool cultures persisting for more than 3 weeks;

  7. Intraoperative identification of the site of a lesion that can not be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source);

  8. Evaluation of acute colonic ischemia/ischemic bowel disease;

  9. Evaluation of patient with Streptococcus bovis endocarditis;

  10. Treatment of bleeding from such lesions as vascular anomalies, ulceration and neoplasia;

  11. Removal of foreign body;

  12. Excision of colonic polyps;

  13. Decompression of pseudo-obstruction of the colon (Olgilvie’s syndrome);

  14. Treatment of sigmoid volvulus or stricture;

  15. Evaluation of unexplained, new onset constipation, refractory to medical therapy;

  16. Evaluation of anorectal polyp (adenomatous polyp only); or,

  17. Palliative treatment of stenosing, bleeding neoplasms (e.g., laser, electrocoagulation, stenting).

Limitations:

Endoscopy is generally not covered for treating the following, and records must have additional documentation indicating the medical necessity of the procedure for review as needed:

  1. Chronic, stable, irritable bowel syndrome, or chronic abdominal pain, There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy;

  2. Acute diarrhea;

  3. Hemorrhoids;

  4. Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management;

  5. Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn’s disease and chronic ulcerative colitis);

  6. Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease;

  7. Upper gastrointestinal (GI) bleeding or melena with a demonstrated upper GI source; or,

  8. Bright red rectal bleeding with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source;


Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy is generally not covered for:

  1. Fulminant colitis;

  2. Possible perforated viscus;

  3. Acute severe diverticulitis; or,

  4. Diverticulosis. This condition is not usually considered an indication for diagnostic or therapeutic colonoscopy, sigmoidoscopy or proctosigmoidoscopy, but may be reported on the claim when this condition is found to be the final diagnosis.



Other Comments:

For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
Summary of Evidence

N/A
Analysis of Evidence (Rationale for Determination)

N/A

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

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Infectious colitis is an acceptable indication in its general form. However, specificity in ICD-10-CM coding is not needed but should be maintained in the patient's chart. The medical record should support the medical necessity and frequency of this treatment.

Physicians/providers must maintain adequate information in the patient's medical record in case it is needed by the contractor to document an incomplete colonoscopy.



Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators, LLC. is not responsible for the continuing viability of Web site addresses listed below.

AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010;138:738–745.

Cotton PB, Durkalski VL, Pineau BC et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA. 2004;291:1713-1719.

Dominitz JA, Eisen GM, Baron TH et al. Complications of colonoscopy. Gastrointest Endosc. 2003;57:441-445.

Fenlon HM, McAneny DB, Nunes DP, Clarke PD, Ferrucci JT. Occlusive colon carcinoma: virtual colonoscopy in the preoperative evaluation of the proximal colon. Radiology. 1999;210:423-428.

The role of colonoscopy in the management of patients with inflammatory bowel disease. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 1998;48:689-690.

Sedation and monitoring of patient undergoing gastrointestinal endoscopic procedures. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 1995;42:626-629.

Beebe M, Dalton J, Espronceda M et al. In: Brockman C. ed. CPT 2007. 4th Revised ed. Chicago, IL: American Medical Association; 2006

Other Medicare contractor policies consulted in development of this draft:

  • AdminaStar Federal carrier LCD (Indiana [L7442], Kentucky [L6909])
  • AdminaStar Federal fiscal intermediary LCD (Illinois [L11642], Indiana [L1615], Kentucky [L11649], Ohio [L11650])
  • Empire Medicare Services carrier LCD (New Jersey [L4017], New York [L8257])
Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
02/01/2024 R22

R23

Revision Effective: 02-01-2024

Revision Explanation: Annual Review, no changes were made.

01-25-2024: 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.
  • Other (Annual Review)
01/26/2023 R21

R22

Revision Effective: 01/26/2023

Revision Explanation: Annual Review, no changes were made.

01/20/2022: 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.
  • Other (Annual Review)
02/03/2022 R20

R21

Revision Effective: 02/03/2022

Revision Explanation: Annual Review, no changes were made.

01/25/2022: 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.
  • Other (Annual Review)
02/04/2021 R19

R20

Revision Effective: 02/04/2021

Revision Explanation: Annual Review, no changes were made.

01/27/2021: 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.
  • Other (Annual Review)
09/19/2019 R18

R19

Revision Effective: N/A

Revision Explanation: Annual REview, no changes made.

1/24/2020: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.
  • Other (Annual Review)
09/19/2019 R17

R18

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. For Approval, no changes.

09/13/2019: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.
  • Revisions Due To Code Removal
09/19/2019 R16

R17

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901.

09/12/2019: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.
  • Revisions Due To Code Removal
04/04/2019 R15

R16
Revision Effective: 04/04/2019
Revision Explanation: Removed all billing and coding details from policy into related Billing and Coding article. Coding information was removed based on CR10901. Also, retired A52382-Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy-Supplemental Instructions Article.

03/29/2019: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.
  • Other
10/01/2018 R14

R15

Revision Effective Date: N/A

Revision Explanation: Annual review no changes made.

01/29/2019: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.
  • Other (Annual Review)
10/01/2018 R13

Revision #:R14

Revision Effective Date: 10/01/2018

Explanation: ICD-10 code I86.8 was included in the paragraph above group 1 ICD-10 codes in error bit was never included in the list of covered codes below the paragraph. REmoved I86.8 from the paragraph as it was a typographical error.

10/24/2018: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.
  • Typographical Error
10/01/2018 R12

Revision #:R13

Revision Effective Date: 10/01/2018

Explanation: During annual ICd-10 update code H83.0 was deleted and replaced with K83.01 and K83.09 in group 1. New codes for 2019 K35.890 and K35.891 were added to group 1.

09/19/2018: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.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R11

Revision #:R12
Revision Effective Date: N/A
Revision Explanation: Annual review no changes made.

01/30/2018: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.

 
  • Other (Annual Review)
10/01/2017 R10

R11

Revision Effective: 10/01/2017

Revision Explanation: During ICd-10 annual review K56.5, K56.60, and K56.69 were deleted from group 1 and replaced with K56.50, K56.51, K56.52, K56.600, K56.601, K56.690, K56.691, and K56.999.

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.

 

 

Revision #:R10
Revision Effective Date: N/A
Revision Explanation: Annual review no changes made.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R9 Revision #:R9
Revision Effective Date: 10/01/2016
Revision Explanation: The following codes were deleted during the annual ICD-10 update K52.2, K55.0, K59.3, and K90.4 and replaced with the following ICd-10 codes:
K52.21, K52.22, K52.29, K52.3(new for 2017), K55.011, K55.012, K55.021, K55.022, K55.031, K55.032, K55.041, K55.042, K55.051, K55.052, K59.31, K59.39, K90.41, K90.49
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R8 Revision #:R8
Revision Effective Date: N/A
Revision Explanation: Correcting typo from revision 5.
HCPCs codes G6019, g6020, and G6023-G6025 were deleted effective 12/31/2015. Replace with CPT codes 44401-44402, 45346, 45347, 45388-45389 effective 01/01/2016

Revision #:R5
Revision Effective Date: 01/01/2016
Revision Explanation: HCPCs codes G6019, g6020, and G60232-G6025 were deleted effective 12/31/2015. Replace with CPT codes 44401-44402, 45646, 45347, 45388-45389 effective 01/01/2016
  • Typographical Error
01/01/2016 R7 Revision#:R7
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual review)
01/01/2016 R6 Revision #:R6
Revision Effective Date: 01/01/2016
Revision Explanation: span of N32.1-N82.4 was done in error. should have been N32.1 and spanned N82.2-N82.4.
  • Typographical Error
01/01/2016 R5 Revision #:R5
Revision Effective Date: 01/01/2016
Revision Explanation: HCPCs codes G6019, g6020, and G60232-G6025 were deleted effective 12/31/2015. Replace with CPT codes 44401-44402, 45646, 45347, 45388-45389 effective 01/01/2016
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R4 Revision #:R4
Revision Effective Date: 10/01/2015
Revision Explanation: Corrected Z09 to Z08 in paragraph concerning surveillance colonic neoplasia.
  • Typographical Error
10/01/2015 R3 Revision #:R3
Revision Effective Date: 10/01/2015
Revision Explanation: Typographical error Z09 should be Z08 corrected in group one.
  • Typographical Error
10/01/2015 R2 Revision #:R2
Revision Effective Date: 10/01/2015
Revision Explanation: Codes 44401-44402, 45346, 45347, 45388, and 45389 added in error. Removed these codes from the policy.
  • Typographical Error
10/01/2015 R1 Revision#: R1
Revision Effective: 10/01/2015
Revision Explanation: Codes 44393, 44397, 45339, 45345, 45355, 45383, and 45387 deleted during annual code update. HCPCS codes G6019-G6020, G6022-G6025, and 45399 are replacing deleted codes. Added 4401-4402, 45346-45347, 45388-45389, and 45399 that are new for 2015
  • Revisions Due To CPT/HCPCS Code Changes
N/A

Associated Documents

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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
01/25/2024 02/01/2024 - N/A Currently in Effect You are here
01/20/2023 01/26/2023 - 01/31/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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