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1 PROPOSED/DRAFT Local Coverage Determination (LCD): Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy (DL34454) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Please note: This is a Proposed/Draft policy. Proposed/Draft LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed/Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) Palmetto GBA A and B and HHH MAC MAC A J - M South Carolina Palmetto GBA A and B and HHH MAC MAC B J - M South Carolina Palmetto GBA A and B and HHH MAC MAC A J - M Virginia Palmetto GBA A and B and HHH MAC MAC B J - M Virginia Palmetto GBA A and B and HHH MAC MAC A J - M West Virginia Palmetto GBA A and B and HHH MAC MAC B J - M West Virginia Palmetto GBA A and B and HHH MAC MAC A J - M North Carolina Palmetto GBA A and B and HHH MAC MAC B J - M North Carolina Back to Top Proposed/Draft LCD Information Document Information Source LCD ID L34454 Proposed LCD ID DL34454 Proposed LCD Title Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. Printed on 1/18/2017. Page 1 of 17

2 UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. 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 [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 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. Title XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. 42 CFR Section indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements). CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 6, 20.2 Outpatient Defined CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 6, 20.3 Encounter Defined CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 6, Diagnostic Services Defined CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 6, Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010 CMS Internet-Only Manual, Pub , Medicare Claims Processing Manual, Chapter 12, 30.1 Digestive System 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 or small intestine proximal to an anastomosis. 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. Incomplete colonoscopies are defined as the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances. Indications: The following are Medicare-covered indications: Printed on 1/18/2017. Page 2 of 17

3 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: a. Hematochezia not thought to be from rectum or perianal source b. Melena of unknown origin c. 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, use the appropriate diagnostic CPT code with the appropriate -CM code and one of the following -CM codes as the secondary diagnosis: Z85.038, Z or Z86.010; a. Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp; b. 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. HCPCS code G0105 should be reported; c. 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); d. 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; Printed on 1/18/2017. Page 3 of 17

4 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. Marking of neoplasm for localization (tattooing) is covered, but is not separately payable. Other Comments: 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. Printed on 1/18/2017. Page 4 of 17

5 Back to Top Proposed/Draft Process Information Synopsis of Changes Changes Fields Changed Under that Support Medical Necessity deleted codes K50.00, that K50.011, K50.012, K50.013, K50.014, K50.018, K50.019, K56.1, K80.30, K80.31, K80.32, Support Medical K80.33, K80.34, K80.35, K80.36, K80.37, K83.0, Z85.01 and Z Necessity Associated Information Documentation Requirements The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See Coverage Indications, Limitations and/or Medical Necessity). 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. Specificity in 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. Documentation supporting the medical necessity should be legible, relevant, and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request. Utilization Guidelines When a diagnostic colonoscopy, sigmoidoscopy or proctosigmoidoscopy is performed and the findings are normal, or did not provide a diagnosis, please report the symptom(s) for which the endoscopy was performed. Sources of Information and Basis for Decision Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. Jour of the Amer Med Assoc. 2004;291(14): Farraye FA, Odze RD, Eaden J, et al. AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010;138(2): 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(2): Fisher DA, Maple JT, Ben-Menachem T, et al. Complications of colonoscopy. Gastrointest Endosc. 2011;74(4): Sedation and monitoring of patients undergoing gastrointestinal endoscopic procedures. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 1995;42(6): Kim YG, Jang BI. The role of colonoscopy in inflammatory bowel disease. Clin Endosc. 2013;46(4): Open Meetings/Part B MAC Contractor Advisory Committee (CAC) Meetings Meeting Date Meeting Type Meeting State(s) Meeting Information 02/06/2017 Open Meeting South Carolina Columbia 02/06/2017 Carrier Advisory Committee (CAC) Meeting South Carolina Columbia Comment Period Start Date 02/06/2017 Comment Period End Date 03/23/2017 Printed on 1/18/2017. Page 5 of 17

6 Released to Final LCD Date N/A Reason for Proposed LCD Provider Education/Guidance Proposed Contact Part B Policy PO Box AG-275 Columbia, SC B.Policy@PalmettoGBA.com Back to Top Coding Information Bill Type : 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. N/A Revenue : Contractors may specify Revenue to help providers identify those Revenue typically used to report this service. In most instances Revenue are purely advisory. Unless specified in the policy, services reported under other Revenue are equally subject to this coverage determination. Complete absence of all Revenue indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue. N/A CPT/HCPCS Group 1 Paragraph: N/A Group 1 : COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF FOREIGN BODY(S) COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING, ANY METHOD COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE COLONOSCOPY THROUGH STOMA; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE-AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC STENT PLACEMENT (INCLUDING PRE- AND POST DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) PROCTOSIGMOIDOSCOPY, RIGID; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE) PROCTOSIGMOIDOSCOPY, RIGID; WITH BIOPSY, SINGLE OR MULTIPLE PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF FOREIGN BODY PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY Printed on 1/18/2017. Page 6 of 17

7 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY SNARE TECHNIQUE PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS, OR OTHER LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE PROCTOSIGMOIDOSCOPY, RIGID; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) PROCTOSIGMOIDOSCOPY, RIGID; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE (EG, LASER) PROCTOSIGMOIDOSCOPY, RIGID; WITH DECOMPRESSION OF VOLVULUS PROCTOSIGMOIDOSCOPY, RIGID; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S) SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) SIGMOIDOSCOPY, FLEXIBLE; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S) COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC STENT PLACEMENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES that Support Medical Necessity Group 1 Paragraph: The correct use of an code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this Printed on 1/18/2017. Page 7 of 17

8 determination. Please note: For the purposes of this LCD, each code listed in this paragraph represents only the condition as noted during colonoscopy/sigmoidoscopy/proctosigmoidoscopy and should only be reported when that condition exists in the colon, rectum, anus or ileum: A03.9, Bacillary colitis; A07.3, Coccidial colitis; A09, Infectious colitis; A54.6, Gonococcal proctitis; B65.1, Intestinal schistosomiasis; B68.0, Intestinal taeniasis, solium; B68.1, Intestinal taeniasis, saginata; B71.8, Other cestode intestinal infection; D17.79, Lipoma, colon; D18.03, Hemangioma, colon or terminal ileum; D18.1, Lymphangioma, colon or terminal ileum; D49.0, Neoplasm of unspecified nature, colon or small bowel; I86.4, Varices, colon and terminal ileum; K55.031, Focal (segmental) acute (reversible) ischemia of large intestine; K55.032, Diffuse acute (reversible) ischemia of large intestine; K55.039, Acute (reversible) ischemia of large intestine, extent unspecified; K55.041, Focal (segmental) acute infarction of large intestine; K55.042, Diffuse acute infarction of large intestine; K55.049, Acute infarction of large intestine, extent unspecified; K55.051, Focal (segmental) acute (reversible) ischemia of intestine, part unspecified; K55.052, Diffuse acute (reversible) ischemia of intestine, part unspecified; K55.059, Acute (reversible) ischemia of intestine, part and extent unspecified; K56.49, Impaction of colon; K56.3, Impaction of terminal ileum; K57.10, Diverticulosis of terminal ileum without mention of hemorrhage; K57.11, Diverticulosis of terminal ileum with hemorrhage; Q43.3, Malrotation of colon. Please note: For the purposes of this policy code K92.2 also represents portal hypertensive colopathy. code Z09 requires a secondary diagnosis, for example, Z85.038, Z or Z Group 1 : A03.9 Shigellosis, unspecified A04.3 Enterohemorrhagic Escherichia coli infection A04.5 Campylobacter enteritis A04.6 Enteritis due to Yersinia enterocolitica A04.7 Enterocolitis due to Clostridium difficile A04.8 Other specified bacterial intestinal infections A04.9 Bacterial intestinal infection, unspecified A06.1 Chronic intestinal amebiasis A06.2 Amebic nondysenteric colitis A06.9 Amebiasis, unspecified A07.0 Balantidiasis A07.3 Isosporiasis A07.8 Other specified protozoal intestinal diseases A08.0 Rotaviral enteritis A08.11 Acute gastroenteropathy due to Norwalk agent A08.19 Acute gastroenteropathy due to other small round viruses A08.2 Adenoviral enteritis A08.31 Calicivirus enteritis A08.32 Astrovirus enteritis A08.39 Other viral enteritis A09 Infectious gastroenteritis and colitis, unspecified A18.31 Tuberculous peritonitis A18.32 Tuberculous enteritis A18.39 Retroperitoneal tuberculosis A18.83 Tuberculosis of digestive tract organs, not elsewhere classified A54.6 Gonococcal infection of anus and rectum A55 Chlamydial lymphogranuloma (venereum) B20 Human immunodeficiency virus [HIV] disease B37.82 Candidal enteritis B65.1 Schistosomiasis due to Schistosoma mansoni [intestinal schistosomiasis] B68.0 Taenia solium taeniasis B68.1 Taenia saginata taeniasis B68.9 Taeniasis, unspecified B70.0 Diphyllobothriasis B71.0 Hymenolepiasis B71.1 Dipylidiasis B71.8 Other specified cestode infections Printed on 1/18/2017. Page 8 of 17

9 B76.8 Other hookworm diseases B76.9 Hookworm disease, unspecified B77.0 Ascariasis with intestinal complications B77.89 Ascariasis with other complications B77.9 Ascariasis, unspecified B78.0 Intestinal strongyloidiasis B78.7 Disseminated strongyloidiasis B78.9 Strongyloidiasis, unspecified B79 Trichuriasis B80 Enterobiasis B82.0 Intestinal helminthiasis, unspecified B82.9 Intestinal parasitism, unspecified B83.9 Helminthiasis, unspecified C17.2 Malignant neoplasm of ileum 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 C18.9 Malignant neoplasm of colon, unspecified C19 Malignant neoplasm of rectosigmoid junction C20 Malignant neoplasm of rectum C21.0 Malignant neoplasm of anus, unspecified 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 C49.A4 Gastrointestinal stromal tumor of large intestine C49.A5 Gastrointestinal stromal tumor of rectum C49.A9 Gastrointestinal stromal tumor of other sites C7A.00 Malignant carcinoid tumor of unspecified site C7A.020 Malignant carcinoid tumor of the appendix C7A.021 Malignant carcinoid tumor of the cecum C7A.022 Malignant carcinoid tumor of the ascending colon C7A.023 Malignant carcinoid tumor of the transverse colon C7A.024 Malignant carcinoid tumor of the descending colon C7A.025 Malignant carcinoid tumor of the sigmoid colon C7A.026 Malignant carcinoid tumor of the rectum C7A.029 Malignant carcinoid tumor of the large intestine, unspecified portion C7A.096 Malignant carcinoid tumor of the hindgut, unspecified C7A.098 Malignant carcinoid tumors of other sites C7A.1 Malignant poorly differentiated neuroendocrine tumors C7A.8 Other malignant neuroendocrine tumors C7B.04 Secondary carcinoid tumors of peritoneum C7B.09 Secondary carcinoid tumors of other sites C7B.1 Secondary Merkel cell carcinoma C7B.8 Other secondary neuroendocrine tumors C77.2 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes C78.4 Secondary malignant neoplasm of small intestine C78.5 Secondary malignant neoplasm of large intestine and rectum C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct 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 Printed on 1/18/2017. Page 9 of 17

10 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 D12.6 Benign neoplasm of colon, unspecified D12.7 Benign neoplasm of rectosigmoid junction D12.8 Benign neoplasm of rectum D12.9 Benign neoplasm of anus and anal canal D17.5 Benign lipomatous neoplasm of intra-abdominal organs D17.79 Benign lipomatous neoplasm of other sites D18.03 Hemangioma of intra-abdominal structures D18.1 Lymphangioma, any site D3A.00 Benign carcinoid tumor of unspecified site D3A.020 Benign carcinoid tumor of the appendix D3A.021 Benign carcinoid tumor of the cecum D3A.022 Benign carcinoid tumor of the ascending colon D3A.023 Benign carcinoid tumor of the transverse colon D3A.024 Benign carcinoid tumor of the descending colon D3A.025 Benign carcinoid tumor of the sigmoid colon D3A.026 Benign carcinoid tumor of the rectum D3A.029 Benign carcinoid tumor of the large intestine, unspecified portion D3A.8 Other benign neuroendocrine tumors D37.1 Neoplasm of uncertain behavior of stomach D37.2 Neoplasm of uncertain behavior of small intestine 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 D37.9 Neoplasm of uncertain behavior of digestive organ, unspecified 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 I77.2 Rupture of artery I78.0 Hereditary hemorrhagic telangiectasia I86.4 Gastric varices K35.80 Unspecified acute appendicitis K35.89 Other acute appendicitis K38.0 Hyperplasia of appendix K38.1 Appendicular concretions K38.2 Diverticulum of appendix K38.3 Fistula of appendix K38.8 Other specified diseases of appendix K38.9 Disease of appendix, unspecified K50.10 Crohn's disease of large intestine without complications K Crohn's disease of large intestine with rectal bleeding K Crohn's disease of large intestine with intestinal obstruction K Crohn's disease of large intestine with fistula K Crohn's disease of large intestine with abscess K Crohn's disease of large intestine with other complication K Crohn's disease of large intestine with unspecified complications K50.80 Crohn's disease of both small and large intestine without complications K Crohn's disease of both small and large intestine with rectal bleeding K Crohn's disease of both small and large intestine with intestinal obstruction K Crohn's disease of both small and large intestine with fistula K Crohn's disease of both small and large intestine with abscess Printed on 1/18/2017. Page 10 of 17

11 K Crohn's disease of both small and large intestine with other complication K Crohn's disease of both small and large intestine with unspecified complications K50.90 Crohn's disease, unspecified, without complications K Crohn's disease, unspecified, with rectal bleeding K Crohn's disease, unspecified, with intestinal obstruction K Crohn's disease, unspecified, with fistula K Crohn's disease, unspecified, with abscess K Crohn's disease, unspecified, with other complication K Crohn's disease, unspecified, with unspecified complications K51.00 Ulcerative (chronic) pancolitis without complications K Ulcerative (chronic) pancolitis with rectal bleeding K Ulcerative (chronic) pancolitis with intestinal obstruction K Ulcerative (chronic) pancolitis with fistula K Ulcerative (chronic) pancolitis with abscess K Ulcerative (chronic) pancolitis with other complication K Ulcerative (chronic) pancolitis with unspecified complications K51.20 Ulcerative (chronic) proctitis without complications K Ulcerative (chronic) proctitis with rectal bleeding K Ulcerative (chronic) proctitis with intestinal obstruction K Ulcerative (chronic) proctitis with fistula K Ulcerative (chronic) proctitis with abscess K Ulcerative (chronic) proctitis with other complication K Ulcerative (chronic) proctitis with unspecified complications K51.30 Ulcerative (chronic) rectosigmoiditis without complications K Ulcerative (chronic) rectosigmoiditis with rectal bleeding K Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K Ulcerative (chronic) rectosigmoiditis with fistula K Ulcerative (chronic) rectosigmoiditis with abscess K Ulcerative (chronic) rectosigmoiditis with other complication K Ulcerative (chronic) rectosigmoiditis with unspecified complications K51.40 Inflammatory polyps of colon without complications K Inflammatory polyps of colon with rectal bleeding K Inflammatory polyps of colon with intestinal obstruction K Inflammatory polyps of colon with fistula K Inflammatory polyps of colon with abscess K Inflammatory polyps of colon with other complication K Inflammatory polyps of colon with unspecified complications K51.50 Left sided colitis without complications K Left sided colitis with rectal bleeding K Left sided colitis with intestinal obstruction K Left sided colitis with fistula K Left sided colitis with abscess K Left sided colitis with other complication K Left sided colitis with unspecified complications K51.80 Other ulcerative colitis without complications K Other ulcerative colitis with rectal bleeding K Other ulcerative colitis with intestinal obstruction K Other ulcerative colitis with fistula K Other ulcerative colitis with abscess K Other ulcerative colitis with other complication K Other ulcerative colitis with unspecified complications K51.90 Ulcerative colitis, unspecified, without complications K Ulcerative colitis, unspecified with rectal bleeding K Ulcerative colitis, unspecified with intestinal obstruction K Ulcerative colitis, unspecified with fistula K Ulcerative colitis, unspecified with abscess K Ulcerative colitis, unspecified with other complication K Ulcerative colitis, unspecified with unspecified complications Printed on 1/18/2017. Page 11 of 17

12 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 K Collagenous colitis K Lymphocytic colitis K Other microscopic colitis K Microscopic colitis, unspecified K52.89 Other specified noninfective gastroenteritis and colitis K52.9 Noninfective gastroenteritis and colitis, unspecified K Focal (segmental) acute (reversible) ischemia of large intestine K Diffuse acute (reversible) ischemia of large intestine K Acute (reversible) ischemia of large intestine, extent unspecified K Focal (segmental) acute infarction of large intestine K Diffuse acute infarction of large intestine K Acute infarction of large intestine, extent unspecified K Focal (segmental) acute (reversible) ischemia of intestine, part unspecified K Diffuse acute (reversible) ischemia of intestine, part unspecified K Acute (reversible) ischemia of intestine, part and extent unspecified K Focal (segmental) acute infarction of intestine, part unspecified K Diffuse acute infarction of intestine, part unspecified K Acute infarction of intestine, part and extent unspecified K55.1 Chronic vascular disorders of intestine K55.20 Angiodysplasia of colon without hemorrhage K55.21 Angiodysplasia of colon with hemorrhage K55.30 Necrotizing enterocolitis, unspecified 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 K55.9 Vascular disorder of intestine, unspecified K56.0 Paralytic ileus K56.2 Volvulus K56.3 Gallstone ileus K56.49 Other impaction of intestine K56.5 Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection) K56.60 Unspecified intestinal obstruction K56.69 Other intestinal obstruction K56.7 Ileus, unspecified K57.00 Diverticulitis of small intestine with perforation and abscess without bleeding K57.01 Diverticulitis of small intestine with perforation and abscess with bleeding K57.10 Diverticulosis of small intestine without perforation or abscess without bleeding K57.11 Diverticulosis of small intestine without perforation or abscess with bleeding 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 K57.50 Diverticulosis of both small and large intestine without perforation or abscess without bleeding K57.51 Diverticulosis of both small and large intestine without perforation or abscess with bleeding Printed on 1/18/2017. Page 12 of 17

13 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 K57.81 Diverticulitis of intestine, part unspecified, with perforation and abscess with bleeding K57.90 Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding K57.91 Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding K57.93 Diverticulitis of intestine, part unspecified, without perforation or abscess with 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 without diarrhea K59.00 Constipation, unspecified K59.01 Slow transit constipation K59.02 Outlet dysfunction constipation K59.03 Drug induced 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 K59.8 Other specified functional intestinal disorders K62.0 Anal polyp K62.1 Rectal polyp K62.4 Stenosis of anus and rectum K62.5 Hemorrhage of anus and rectum K62.6 Ulcer of anus and rectum K62.81 Anal sphincter tear (healed) (nontraumatic) (old) K62.82 Dysplasia of anus K63.0 Abscess of intestine K63.1 Perforation of intestine (nontraumatic) 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 K64.0 First degree hemorrhoids K64.1 Second degree hemorrhoids K64.2 Third degree hemorrhoids K64.3 Fourth degree hemorrhoids K64.8 Other hemorrhoids K90.49 Malabsorption due to intolerance, not elsewhere classified K90.89 Other intestinal malabsorption K Pouchitis K Other complications of intestinal pouch K Postprocedural hematoma of a digestive system organ or structure following a digestive system procedure K Postprocedural hematoma of a digestive system organ or structure following other procedure K Postprocedural seroma of a digestive system organ or structure following a digestive system procedure K Postprocedural seroma of a digestive system organ or structure following other procedure K91.89 Other postprocedural complications and disorders of digestive system K92.1 Melena K92.2 Gastrointestinal hemorrhage, unspecified K92.89 Other specified diseases of the digestive system Printed on 1/18/2017. Page 13 of 17

14 K94.00 Colostomy complication, unspecified K94.01 Colostomy hemorrhage K94.03 Colostomy malfunction K94.09 Other complications of colostomy K94.10 Enterostomy complication, unspecified K94.11 Enterostomy hemorrhage K94.13 Enterostomy malfunction K94.19 Other complications of enterostomy N28.89 Other specified disorders of kidney and ureter N32.1 Vesicointestinal fistula N82.2 Fistula of vagina to small intestine N82.3 Fistula of vagina to large intestine N82.4 Other female intestinal-genital tract fistulae Q42.0 Congenital absence, atresia and stenosis of rectum with fistula Q42.1 Congenital absence, atresia and stenosis of rectum without fistula Q42.2 Congenital absence, atresia and stenosis of anus with fistula Q42.3 Congenital absence, atresia and stenosis of anus without fistula Q42.8 Congenital absence, atresia and stenosis of other parts of large intestine Q42.9 Congenital absence, atresia and stenosis of large intestine, part unspecified Q43.1 Hirschsprung's disease Q43.2 Other congenital functional disorders of colon Q43.3 Congenital malformations of intestinal fixation Q43.4 Duplication of intestine Q43.5 Ectopic anus Q43.6 Congenital fistula of rectum and anus Q43.7 Persistent cloaca Q43.8 Other specified congenital malformations of intestine Q43.9 Congenital malformation of intestine, unspecified Q85.8 Other phakomatoses, not elsewhere classified R10.0 Acute abdomen R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain 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 R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.13 Vomiting of fecal matter R19.03 Right lower quadrant abdominal swelling, mass and lump R19.04 Left lower quadrant abdominal swelling, mass and lump R19.05 Periumbilic swelling, mass or lump R19.07 Generalized intra-abdominal and pelvic swelling, mass and lump R19.09 Other intra-abdominal and pelvic swelling, mass and lump 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 R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract S36.500A Unspecified injury of ascending [right] colon, initial encounter S36.500D Unspecified injury of ascending [right] colon, subsequent encounter S36.500S Unspecified injury of ascending [right] colon, sequela S36.501A Unspecified injury of transverse colon, initial encounter S36.501D Unspecified injury of transverse colon, subsequent encounter Printed on 1/18/2017. Page 14 of 17

15 S36.501S S36.502A S36.502D S36.502S S36.503A S36.503D S36.503S S36.508A S36.508D S36.508S S36.510A S36.510D S36.510S S36.511A S36.511D S36.511S S36.512A S36.512D S36.512S S36.513A S36.513D S36.513S S36.518A S36.518D S36.518S S36.519A S36.519D S36.519S S36.520A S36.520D S36.520S S36.521A S36.521D S36.521S S36.522A S36.522D S36.522S S36.523A S36.523D S36.523S S36.528A S36.528D S36.528S S36.530A S36.530D S36.530S S36.531A S36.531D S36.531S S36.532A S36.532D S36.532S S36.533A S36.533D S36.533S S36.538A S36.538D Unspecified injury of transverse colon, sequela Unspecified injury of descending [left] colon, initial encounter Unspecified injury of descending [left] colon, subsequent encounter Unspecified injury of descending [left] colon, sequela Unspecified injury of sigmoid colon, initial encounter Unspecified injury of sigmoid colon, subsequent encounter Unspecified injury of sigmoid colon, sequela Unspecified injury of other part of colon, initial encounter Unspecified injury of other part of colon, subsequent encounter Unspecified injury of other part of colon, sequela Primary blast injury of ascending [right] colon, initial encounter Primary blast injury of ascending [right] colon, subsequent encounter Primary blast injury of ascending [right] colon, sequela Primary blast injury of transverse colon, initial encounter Primary blast injury of transverse colon, subsequent encounter Primary blast injury of transverse colon, sequela Primary blast injury of descending [left] colon, initial encounter Primary blast injury of descending [left] colon, subsequent encounter Primary blast injury of descending [left] colon, sequela Primary blast injury of sigmoid colon, initial encounter Primary blast injury of sigmoid colon, subsequent encounter Primary blast injury of sigmoid colon, sequela Primary blast injury of other part of colon, initial encounter Primary blast injury of other part of colon, subsequent encounter Primary blast injury of other part of colon, sequela Primary blast injury of unspecified part of colon, initial encounter Primary blast injury of unspecified part of colon, subsequent encounter Primary blast injury of unspecified part of colon, sequela Contusion of ascending [right] colon, initial encounter Contusion of ascending [right] colon, subsequent encounter Contusion of ascending [right] colon, sequela Contusion of transverse colon, initial encounter Contusion of transverse colon, subsequent encounter Contusion of transverse colon, sequela Contusion of descending [left] colon, initial encounter Contusion of descending [left] colon, subsequent encounter Contusion of descending [left] colon, sequela Contusion of sigmoid colon, initial encounter Contusion of sigmoid colon, subsequent encounter Contusion of sigmoid colon, sequela Contusion of other part of colon, initial encounter Contusion of other part of colon, subsequent encounter Contusion of other part of colon, sequela Laceration of ascending [right] colon, initial encounter Laceration of ascending [right] colon, subsequent encounter Laceration of ascending [right] colon, sequela Laceration of transverse colon, initial encounter Laceration of transverse colon, subsequent encounter Laceration of transverse colon, sequela Laceration of descending [left] colon, initial encounter Laceration of descending [left] colon, subsequent encounter Laceration of descending [left] colon, sequela Laceration of sigmoid colon, initial encounter Laceration of sigmoid colon, subsequent encounter Laceration of sigmoid colon, sequela Laceration of other part of colon, initial encounter Laceration of other part of colon, subsequent encounter Printed on 1/18/2017. Page 15 of 17

16 S36.538S Laceration of other part of colon, sequela S36.590A Other injury of ascending [right] colon, initial encounter S36.590D Other injury of ascending [right] colon, subsequent encounter S36.590S Other injury of ascending [right] colon, sequela S36.591A Other injury of transverse colon, initial encounter S36.591D Other injury of transverse colon, subsequent encounter S36.591S Other injury of transverse colon, sequela S36.592A Other injury of descending [left] colon, initial encounter S36.592D Other injury of descending [left] colon, subsequent encounter S36.592S Other injury of descending [left] colon, sequela S36.593A Other injury of sigmoid colon, initial encounter S36.593D Other injury of sigmoid colon, subsequent encounter S36.593S Other injury of sigmoid colon, sequela S36.598A Other injury of other part of colon, initial encounter S36.598D Other injury of other part of colon, subsequent encounter S36.598S Other injury of other part of colon, sequela S36.599A Other injury of unspecified part of colon, initial encounter S36.599D Other injury of unspecified part of colon, subsequent encounter S36.599S Other injury of unspecified part of colon, sequela S36.60XA Unspecified injury of rectum, initial encounter S36.60XD Unspecified injury of rectum, subsequent encounter S36.60XS Unspecified injury of rectum, sequela S36.61XA Primary blast injury of rectum, initial encounter S36.61XD Primary blast injury of rectum, subsequent encounter S36.61XS Primary blast injury of rectum, sequela S36.62XA Contusion of rectum, initial encounter S36.62XD Contusion of rectum, subsequent encounter S36.62XS Contusion of rectum, sequela S36.63XA Laceration of rectum, initial encounter S36.63XD Laceration of rectum, subsequent encounter S36.63XS Laceration of rectum, sequela S36.69XA Other injury of rectum, initial encounter S36.69XD Other injury of rectum, subsequent encounter S36.69XS Other injury of rectum, sequela T18.8XXS Foreign body in other parts of alimentary tract, sequela Z85.00 Personal history of malignant neoplasm of unspecified digestive organ Z Personal history of other malignant neoplasm of large intestine Z Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus Z85.05 Personal history of malignant neoplasm of liver Z Personal history of colonic polyps Z87.19 Personal history of other diseases of the digestive system that DO NOT Support Medical Necessity N/A Additional Information Back to Top Associated Documents Attachments N/A Related Local Coverage Documents N/A Printed on 1/18/2017. Page 16 of 17

17 Related National Coverage Documents N/A Back to Top Keywords Colonoscopy Sigmoidoscopy Proctosigmoidoscopy Back to Top Read the LCD Disclaimer Printed on 1/18/2017. Page 17 of 17