LCD Reference Article Billing and Coding Article

Billing and Coding: Diagnostic Colonoscopy

A58428

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A58428
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Diagnostic Colonoscopy
Article Type
Billing and Coding
Original Effective Date
03/21/2021
Revision Effective Date
10/01/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38812 (Diagnostic Colonoscopy). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  1. Medical record documentation (office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the colonoscopy procedure. The procedure results/report and any associated pathology report must be included in the patient's medical record.
  2. If the provider of the colonoscopy is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of procedure results/report and pathology report along with copies of the ordering/referring physician's order for the procedure.
  3. The patient’s medical record should contain documentation to support an incomplete procedure.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(239 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide limited coverage for CPT codes 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398

Group 1 Codes
Code Description
A09 Infectious gastroenteritis and colitis, unspecified
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.1 Malignant neoplasm of anal canal
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C46.4 Kaposi's sarcoma of gastrointestinal sites
C49.A4 Gastrointestinal stromal tumor of large intestine
C49.A5 Gastrointestinal stromal tumor of rectum
C49.A9 Gastrointestinal stromal tumor of other sites
C78.5 Secondary malignant neoplasm of large intestine and rectum
C80.0 Disseminated malignant neoplasm, unspecified
C82.09 Follicular lymphoma grade I, extranodal and solid organ sites
C82.19 Follicular lymphoma grade II, extranodal and solid organ sites
C82.29 Follicular lymphoma grade III, unspecified, extranodal and solid organ sites
C82.39 Follicular lymphoma grade IIIa, extranodal and solid organ sites
C82.49 Follicular lymphoma grade IIIb, extranodal and solid organ sites
C82.89 Other types of follicular lymphoma, extranodal and solid organ sites
C82.99 Follicular lymphoma, unspecified, extranodal and solid organ sites
C83.398 Diffuse large B-cell lymphoma of other extranodal and solid organ sites
C88.40 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] not having achieved remission
D01.0 Carcinoma in situ of colon
D01.1 Carcinoma in situ of rectosigmoid junction
D01.2 Carcinoma in situ of rectum
D01.3 Carcinoma in situ of anus and anal canal
D12.0 Benign neoplasm of cecum
D12.1 Benign neoplasm of appendix
D12.2 Benign neoplasm of ascending colon
D12.3 Benign neoplasm of transverse colon
D12.4 Benign neoplasm of descending colon
D12.5 Benign neoplasm of sigmoid colon
D12.7 Benign neoplasm of rectosigmoid junction
D12.8 Benign neoplasm of rectum
D12.9 Benign neoplasm of anus and anal canal
D37.3 Neoplasm of uncertain behavior of appendix
D37.4 Neoplasm of uncertain behavior of colon
D37.5 Neoplasm of uncertain behavior of rectum
D37.8 Neoplasm of uncertain behavior of other specified digestive organs
D49.0 Neoplasm of unspecified behavior of digestive system
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D50.9 Iron deficiency anemia, unspecified
D62 Acute posthemorrhagic anemia
K50.00 Crohn's disease of small intestine without complications
K50.011 Crohn's disease of small intestine with rectal bleeding
K50.013 Crohn's disease of small intestine with fistula
K50.018 Crohn's disease of small intestine with other complication
K50.10 Crohn's disease of large intestine without complications
K50.111 Crohn's disease of large intestine with rectal bleeding
K50.112 Crohn's disease of large intestine with intestinal obstruction
K50.113 Crohn's disease of large intestine with fistula
K50.114 Crohn's disease of large intestine with abscess
K50.118 Crohn's disease of large intestine with other complication
K50.80 Crohn's disease of both small and large intestine without complications
K50.811 Crohn's disease of both small and large intestine with rectal bleeding
K50.812 Crohn's disease of both small and large intestine with intestinal obstruction
K50.813 Crohn's disease of both small and large intestine with fistula
K50.814 Crohn's disease of both small and large intestine with abscess
K50.818 Crohn's disease of both small and large intestine with other complication
K50.90 Crohn's disease, unspecified, without complications
K50.911 Crohn's disease, unspecified, with rectal bleeding
K50.912 Crohn's disease, unspecified, with intestinal obstruction
K50.913 Crohn's disease, unspecified, with fistula
K50.914 Crohn's disease, unspecified, with abscess
K50.918 Crohn's disease, unspecified, with other complication
K51.00 Ulcerative (chronic) pancolitis without complications
K51.011 Ulcerative (chronic) pancolitis with rectal bleeding
K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction
K51.013 Ulcerative (chronic) pancolitis with fistula
K51.014 Ulcerative (chronic) pancolitis with abscess
K51.018 Ulcerative (chronic) pancolitis with other complication
K51.20 Ulcerative (chronic) proctitis without complications
K51.211 Ulcerative (chronic) proctitis with rectal bleeding
K51.212 Ulcerative (chronic) proctitis with intestinal obstruction
K51.213 Ulcerative (chronic) proctitis with fistula
K51.214 Ulcerative (chronic) proctitis with abscess
K51.218 Ulcerative (chronic) proctitis with other complication
K51.30 Ulcerative (chronic) rectosigmoiditis without complications
K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding
K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction
K51.313 Ulcerative (chronic) rectosigmoiditis with fistula
K51.314 Ulcerative (chronic) rectosigmoiditis with abscess
K51.318 Ulcerative (chronic) rectosigmoiditis with other complication
K51.40 Inflammatory polyps of colon without complications
K51.411 Inflammatory polyps of colon with rectal bleeding
K51.412 Inflammatory polyps of colon with intestinal obstruction
K51.413 Inflammatory polyps of colon with fistula
K51.414 Inflammatory polyps of colon with abscess
K51.418 Inflammatory polyps of colon with other complication
K51.50 Left sided colitis without complications
K51.511 Left sided colitis with rectal bleeding
K51.512 Left sided colitis with intestinal obstruction
K51.513 Left sided colitis with fistula
K51.514 Left sided colitis with abscess
K51.518 Left sided colitis with other complication
K51.80 Other ulcerative colitis without complications
K51.811 Other ulcerative colitis with rectal bleeding
K51.812 Other ulcerative colitis with intestinal obstruction
K51.813 Other ulcerative colitis with fistula
K51.814 Other ulcerative colitis with abscess
K51.818 Other ulcerative colitis with other complication
K51.90 Ulcerative colitis, unspecified, without complications
K51.911 Ulcerative colitis, unspecified with rectal bleeding
K51.912 Ulcerative colitis, unspecified with intestinal obstruction
K51.913 Ulcerative colitis, unspecified with fistula
K51.914 Ulcerative colitis, unspecified with abscess
K51.918 Ulcerative colitis, unspecified with other complication
K52.0 Gastroenteritis and colitis due to radiation
K52.1 Toxic gastroenteritis and colitis
K52.21 Food protein-induced enterocolitis syndrome
K52.22 Food protein-induced enteropathy
K52.29 Other allergic and dietetic gastroenteritis and colitis
K52.3 Indeterminate colitis
K52.81 Eosinophilic gastritis or gastroenteritis
K52.82 Eosinophilic colitis
K52.831 Collagenous colitis
K52.832 Lymphocytic colitis
K52.838 Other microscopic colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
K55.031 Focal (segmental) acute (reversible) ischemia of large intestine
K55.032 Diffuse acute (reversible) ischemia of large intestine
K55.041 Focal (segmental) acute infarction of large intestine
K55.042 Diffuse acute infarction of large intestine
K55.1 Chronic vascular disorders of intestine
K55.20 Angiodysplasia of colon without hemorrhage
K55.21 Angiodysplasia of colon with hemorrhage
K55.31 Stage 1 necrotizing enterocolitis
K55.32 Stage 2 necrotizing enterocolitis
K55.33 Stage 3 necrotizing enterocolitis
K55.8 Other vascular disorders of intestine
K56.0 Paralytic ileus
K56.1 Intussusception
K56.2 Volvulus
K56.49 Other impaction of intestine
K56.50 Intestinal adhesions [bands], unspecified as to partial versus complete obstruction
K56.51 Intestinal adhesions [bands], with partial obstruction
K56.52 Intestinal adhesions [bands] with complete obstruction
K56.600 Partial intestinal obstruction, unspecified as to cause
K56.601 Complete intestinal obstruction, unspecified as to cause
K56.690 Other partial intestinal obstruction
K56.691 Other complete intestinal obstruction
K56.699 Other intestinal obstruction unspecified as to partial versus complete obstruction
K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding
K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding
K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding
K57.31 Diverticulosis of large intestine without perforation or abscess with bleeding
K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding
K57.33 Diverticulitis of large intestine without perforation or abscess with bleeding
K57.40 Diverticulitis of both small and large intestine with perforation and abscess without bleeding
K57.41 Diverticulitis of both small and large intestine with perforation and abscess with bleeding
K57.51 Diverticulosis of both small and large intestine without perforation or abscess with bleeding
K57.52 Diverticulitis of both small and large intestine without perforation or abscess without bleeding
K57.53 Diverticulitis of both small and large intestine without perforation or abscess with bleeding
K57.80 Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding
K58.0 Irritable bowel syndrome with diarrhea
K58.1 Irritable bowel syndrome with constipation
K58.2 Mixed irritable bowel syndrome
K58.8 Other irritable bowel syndrome
K58.9 Irritable bowel syndrome, unspecified
K59.01 Slow transit constipation
K59.02 Outlet dysfunction constipation
K59.04 Chronic idiopathic constipation
K59.09 Other constipation
K59.1 Functional diarrhea
K59.2 Neurogenic bowel, not elsewhere classified
K59.31 Toxic megacolon
K59.39 Other megacolon
K59.4 Anal spasm
K59.81 Ogilvie syndrome
K59.89 Other specified functional intestinal disorders
K62.0 Anal polyp
K62.1 Rectal polyp
K62.2 Anal prolapse
K62.3 Rectal prolapse
K62.4 Stenosis of anus and rectum
K62.5 Hemorrhage of anus and rectum
K62.6 Ulcer of anus and rectum
K62.7 Radiation proctitis
K62.82 Dysplasia of anus
K62.89 Other specified diseases of anus and rectum
K63.2 Fistula of intestine
K63.3 Ulcer of intestine
K63.4 Enteroptosis
K63.5 Polyp of colon
K63.81 Dieulafoy lesion of intestine
K63.89 Other specified diseases of intestine
K91.1 Postgastric surgery syndromes
K91.850 Pouchitis
K91.858 Other complications of intestinal pouch
K91.89 Other postprocedural complications and disorders of digestive system
K92.1 Melena
K94.01 Colostomy hemorrhage
K94.02 Colostomy infection
K94.03 Colostomy malfunction
K94.09 Other complications of colostomy
K94.11 Enterostomy hemorrhage
K94.12 Enterostomy infection
K94.13 Enterostomy malfunction
K94.19 Other complications of enterostomy
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain, unspecified
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.813 Right lower quadrant abdominal tenderness
R10.814 Left lower quadrant abdominal tenderness
R10.815 Periumbilic abdominal tenderness
R10.817 Generalized abdominal tenderness
R10.84 Generalized abdominal pain
R19.4 Change in bowel habit
R19.5 Other fecal abnormalities
R19.7 Diarrhea, unspecified
R19.8 Other specified symptoms and signs involving the digestive system and abdomen
R63.4 Abnormal weight loss
R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
T18.4XXA Foreign body in colon, initial encounter
T18.4XXD Foreign body in colon, subsequent encounter
T18.4XXS Foreign body in colon, sequela
Z85.01 Personal history of malignant neoplasm of esophagus
Z85.020 Personal history of malignant carcinoid tumor of stomach
Z85.028 Personal history of other malignant neoplasm of stomach
Z85.030 Personal history of malignant carcinoid tumor of large intestine
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.040 Personal history of malignant carcinoid tumor of rectum
Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z85.05 Personal history of malignant neoplasm of liver
Z86.0100 Personal history of colon polyps, unspecified
Z86.0101 Personal history of adenomatous and serrated colon polyps
Z86.0102 Personal history of hyperplastic colon polyps
Z86.0109 Personal history of other colon polyps
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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N/A

Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2024 R5

Article revised and published on 10/24/2024 effective for dates of service on and after 10/01/2024 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been deleted and therefore has been removed from the article: C83.39, C88.4 and Z86.010 in Code Group 1. The following ICD-10-CM codes have been added to the article: C83.398, C88.40, Z86.0100, Z86.0101, Z86.0102 and Z86.0109 in Code Group 1. The following ICD-10-CM code has been revised from the article: K58.9 in Code Group 1.

06/14/2021 R4

Article revised and published on 11/11/2021 effective for dates of service on and after 06/14/2021. The following ICD-10-CM codes have been added to the list of ICD-10-CM codes that support medical necessity, Group 1 codes: K50.00, K50.90, K51.90, K51.911, K51.912, K51.913, K51.914, and K51.918, in response to an external inquiry.

06/14/2021 R3

Article revised and published on 08/12/2021 effective for dates of service on and after 06/14/2021. The following ICD-10-CM codes have been added to the list of ICD-10-CM codes that support medical necessity, Group 1 codes: Z85.01, Z85.020, Z85.028, Z85.040, Z85.048 and Z85.05.

05/04/2021 R2

Article revised and published on 07/08/2021 effective for dates of service on and after 05/04/2021. The following ICD-10 codes have been added to the list of ICD-10 -CM codes that support medical necessity, Group 1 codes: Z85.030 and Z85.038.

03/21/2021 R1

Article revised and published on 06/10/2021 effective for dates of service on and after 03/21/2021. The following ICD-10-CM codes have been added to the list of ICD-10-CM codes that support medical necessity, Group 1 codes: D50.9, D62, K57.30, R10.30, R10.31, R10.32, R10.33, R10.813, R10.814, R10.815, R10.817, R10.84, Z86.010.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L38812 - Diagnostic Colonoscopy
Related National Coverage Documents
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