Oct-Nov 00 Part A Bulletin - Medicare

LOCAL AND FOCUSED MEDICAL REVIEW POLICIES
44388: Colonoscopy (continued)
and unspecified digestive organs
239.0 Neoplasm of unspecified nature of
digestive system
280.0 Iron deficiency anemias secondary to
blood loss (chronic)
280.9 Iron deficiency anemia, unspecified
281.9 Unspecified deficiency anemia
448.0 Hereditary hemorrhagic telangiectasia
555.0-555.9 Regional enteritis
556.0-556.9 Ulcerative colitis
557.0-557.9 Vascular insufficiency of intestine
558.1-558.9 Other noninfectious gastroenteritis and
colitis
560.0 Intussusception
560.1 Paralytic ileus
560.2 Volvulus
560.30-560.39 Impaction of intestine
560.81-560.89 Other specified intestinal obstruction
560.9 Unspecified intestinal obstruction
562.11 Diverticulitis of colon (without mention of
hemorrhage)
562.12 Diverticulosis of colon with hemorrhage
562.13 Diverticulitis of colon with hemorrhage
564.0 Constipation
564.1 Irritable bowel syndrome
564.4 Other postoperative functional digestive
disorders
564.5 Functional diarrhea
564.7 Megacolon, other than Hirschsprung’s
564.81-564.89 Other specified functional disorders of the
intestine
569.0 Anal and rectal polyp
569.3 Hemorrhage or rectum and anus
569.41 Ulcer of anus and rectum
569.49 Other specified disorders of rectum and
anus
569.5 Abscess of intestine
569.60-569.69 Colostomy and enterostomy complications
569.81-569.89 Other specified disorders of intestine
578.1 Blood in stool
578.9 Hemorrhage of gastrointestinal tract,
unspecified
783.21 Loss of weight
787.3 Flatulence, eructation, and gas pain
787.6 Incontinence of feces
787.91-787.99 Other symptoms involving digestive
system
789.00-789.09 Abdominal pain
789.30-789.39 Abdominal or pelvic swelling, mass, or
lump
789.60-789.69 Abdominal tenderness
792.1 Nonspecific abnormal findings in stool
contents
793.4 Nonspecific abnormal findings on
radiological and other examination of the
gastrointestinal tract
936 Foreign body in intestine or colon
V10.05 Personal history of malignant neoplasm of
large intestine
V10.06 Personal history of malignant neoplasm of
rectum, rectosigmoid junction, and anus
V12.72 Personal history of colonic polyps
Diagnosis that Support Medical Necessity
N/A
ICD-9-CM Codes that DO NOT
Support Medical Necessity
N/A
Diagnosis that DO NOT Support
Medical Necessity
N/A
Reasons for Denial
When performed for indications other than those listed
in the “Indications and Limitations of Coverage and/or
Medical Necessity” section of this policy.
Noncovered ICD-9-CM Code(s)
Any diagnosis codes not listed in the “ICD-9-CM Codes
That Support Medical Necessity” section of this policy.
Noncovered Diagnosis
N/A
Coding Guidelines
For screening colonoscopies, refer to Florida
Medicare’s Medical Policy AG0104 (Colorectal Cancer
Screening).
Documentation Requirements
Medical record documentation (office/progress notes)
maintained by the ordering/referring physician must indicate
the medical necessity of the colonoscopy procedure covered
by the Medicare program. The procedure results/report and
any associated pathology report must be included in the
patient’s medical record.
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.
Utilization Guidelines
N/A
Other Comments
N/A
Sources of Information
Practice Parameters Committee of the American College of
Gastroenterology
The American Journal of Gastroenterology
The New England Journal of Medicine
The U.S. Preventive Services Task Force, Washington, D.C.
Advisory Committee Notes
This policy does not reflect the sole opinion of the
contractor or Contractor Medical Director. Although the
final decision rests with the contractor, this policy was
developed in cooperation with the contractor’s Advisory
Committee, which includes representatives from the
Gastroenterology Society.
Start Date of Comment Period
N/A
20 The Florida Medicare A Bulletin
October/November 2000