Oct-Nov 00 Part A Bulletin - Medicare

LOCAL AND FOCUSED MEDICAL REVIEW POLICIES
44388: Colonoscopy
Policy Overview: The “ICD-9-CM Codes that Support Medical Necessity” section of the policy has been revised to include
changes and additions affected by the implementation of the 2001 ICD-9-CM update.
Policy Number
44388
Contractor Name
First Coast Service Options, Inc.
Contractor Number
090
Contractor Type
Intermediary
LMRP Title
Colonoscopy
AMA CPT Copyright Statement
CPT codes, descriptions, and other data only are
copyright 1998 American Medical Association (or such
other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS Apply.
HCFA National Coverage Policy
Coverage Issues Manual, Section 35-59
Primary Geographic Jurisdiction
Florida
Secondary Geographic Jurisdiction
N/A
HCFA Region
Region IV
HCFA Consortium
Southern
Policy Effective Date
07/13/1998
Revision Effective Date
10/01/2000
Revision Ending Effective Date
09/30/2000
Policy Ending Date
N/A
LMRP Description
Colonoscopy allows direct visual examination of the
intestinal tract with a flexible tube containing light
transmitting glass fibers that return a magnified image.
Colonoscopy can act as both a diagnostic and therapeutic
tool in the same procedure. Therapeutic indications include
removal of polyps or foreign bodies, hemostasis by
coagulation, and removal of tumors.
Indications and Limitations of Coverage
and/or Medical Necessity
Florida Medicare will consider a colonoscopy to be
medically necessary under any of the following
circumstances (see Covered ICD-9-CM Codes):
• Evaluation of an abnormality on barium enema which is
likely to be clinically significant, such as a filling defect
or stricture.
• Evaluation and excision of polyps detected by barium
enema or flexible sigmoidoscopy.
• Evaluation of unexplained gastrointestinal bleeding;
hematochezia not thought to be from rectum or perianal
source, melena of unknown origin, or presence of fecal
occult blood.
• Unexplained iron deficiency anemia.
• Examination to evaluate the entire colon for
simultaneous cancer or neoplastic polyps in a patient
with a treatable cancer or neoplastic polyp.
• Evaluation of a patient with carcinoma of the colon
before bowel resection. Post surgical follow-up should
be conducted annually for 2 years and every 2 years
thereafter.
• Yearly evaluation with multiple biopsies for detection of
cancer and dysplasia for patients with chronic ulcerative
colitis who have had pancolitis of greater than seven
years duration.
• Yearly evaluation with multiple biopsies for detection of
cancer and dysplasia for patients with chronic ulcerative
colitis who have had left-sided colitis of over 15 years
duration (not indicated for disease limited to
rectosigmoid).
• Chronic inflammatory bowel disease of the colon when
more precise diagnosis or determination of the extent of
activity of disease will influence immediate
management.
• Clinically significant diarrhea of unexplained origin.
• Treatment of bleeding from such lesions as vascular
anomalies, ulceration, neoplasia, and polypectomy site
(e.g., electrocoagulation, heater probe, laser or injection
therapy).
• Foreign body removal.
• Decompression of acute non-toxic megacolon.
• Balloon dilation of stenotic lesions (e.g., anastomotic
strictures).
• Decompression of colonic volvulus.
• Examination and evaluation when a change in
management is probable or is being suspected based on
results of the colonoscopy.
• Evaluation within 6 months of the removal of sessile
polyps to determine and document total excision. If
evaluation indicates that residual polyp is present,
excision should be done with repeat colonoscopy within
6 months. After evidence of total excision without
return of the polyp, repeat colonoscopy yearly.
• If a total colonoscopy is unsuccessful preoperatively
due to obstructive cancer, repeat colonoscopy 3-6
months post-operatively unless unresectable metastases
are found at surgery.
18 The Florida Medicare A Bulletin
October/November 2000