Response to Comments: Diagnostic and Therapeutic Colonoscopy (A55558)

Noridian's Response to Provider Recommendations (for comment period ending 12/15/16).

Comment Response
The indication for coverage should be changed from "abnormality on barium enema" to "abnormality on radiology study." There are times when an abnormality on radiology studies, other than a barium enema, leads to a colonoscopy. For example, colon masses are a common incidental finding on a CT of the abdomen and pelvis. There are also patients who do "virtual" colonoscopies via high resolution CT. The test of choice in this case would be a colonoscopy, where a tissue diagnosis can be obtained, and not a barium enema. I can think of other examples as well: colon mass on ultrasound and dilated colon on abdominal X-ray. All members of the representative societies present supported this amendment to the LCD on colonoscopy. Noridian agrees with this recommendation and has amended the wording to reflect this input as well as separating a radiological finding from other indications in that same bullet point. Evaluation of an abnormality discovered by an imaging examination wherein the findings of the imaging study are consistent with a colonic lesion that is likely to be clinically significant.
Ninth bullet: Intraoperative identification of the site of a lesion... consider allowing intraoperative for other reasons and not just the site of lesion such as for leaks, patency, bleeding, pouch formation. Bullet point was amended to reflect this request.
  • Intraoperative visualization of the site of a lesion for findings that are suspected but that cannot be confirmed/detected by palpation or gross inspection at surgery. Examples include bleeding or perforation and the reason for the visualization must be clearly described in the procedure note.
Under colonoscopy is not covered: Eighth bullet, the statement ...and no other symptoms suggestive... physician doesn't always know this is the source. It could be a total normal colon other than a hemorrhoid. Amended to read:
  • Upper GI bleeding or melena with a demonstrated upper GI source and absence of findings suggestive of a lower GI bleeding site.
Under colonoscopy is contraindicated: Suspected perforated viscus – unless the colonoscopy is for treatment of perforation itself and placement of clips to close colonic perforation. Amended to read:
  • Suspected perforated viscus. A therapeutic colonoscopy by a trained endoscopist capable of repairing a perforation site may be allowed when the clinical findings and imaging studies strongly indicate that a perforation has occurred and the suspected site of the perforation allows for endoscopic repair.
Under documentation requirements: The colonoscopy report must describe the following: penetration by location description (ie, centimeters) doesn't mean anything. Should not be allowed. This requirement does not require distance in centimeters but does require documentation of the depth of penetration to assure proper billing. A complete colonoscopy includes examination of the cecum. Failure to achieve this endpoint requires billing as an incomplete study. It is acceptable to stet language similar to "the scope was advanced to the cecum". An exception is in a therapeutic colonoscopy where the actual distance to the lesion may be of benefit to subsequent care but does not necessarily require visualization of the cecum unless clinically indicated.
Second paragraph to the end of this section is in regards to modifier 22. "Submit this claim by paper with an attachment..." This language should be changed since paper claims are not accepted for most practices. Language in this same section, paragraph 2, should be used to be consistent in how modifier 22 claims should be submitted. Noridian feels this statement clearly indicates that no medical records are necessary unless modifier -22 is used. In the latter case an additional documentation request will be sent by Noridian. Medical records may be requested at any time a Medicare auditor determines a reason for such review.
Added diagnosis codes: A07 – diarrhea, unknown origin A07 is no longer a valid ICD-10 code for 2017. In its place one may choose to use K52.89 – other specified noninfective gastroenteritis and colitis.
Under Coverage Indications: include relative or personal history of cancer. Relative with cancer is not a covered indication for a diagnostic colonoscopy in the absence of clinical findings. A screening colonoscopy may be covered in such circumstances. Please refer to the CMS Preventive Services benefits for further information. Personal history of cancer is vague. Surveillance in accordance with established guidelines for colon cancer follow up are covered.
Under additional findings in the coding section: There are several indications that could be covered but the ICD-10 code is not included in the covered diagnosis list. Unable to act on this due to lack of information as to what indications the commenter wanted covered.
Please consider adding the following diagnosis codes to the policy: Diagnosis Code Description R15.9 Full incontinence of feces R15.0 Incomplete Defecation R15.1 Fecal smearing R15.2 Fecal Urgency K52.831 Collagenous colitis. K51.90 Ulcerative colitis, without complications K52.9 Non-infective gastroenteritis and colitis, unspecified On the first four codes these are normally amenable to flexible sigmoidoscopy. In the unusual event a full colonoscopy is needed this can be addressed at redetermination. The last three codes are mostly unspecified and suitable alternatives are available in the policy. None of our gastroenterology reviewers asked for these codes to be added.
Per MLN Matters SE0613 - Colorectal Cancer: Preventable, Treatable, and Beatable: Medicare Coverage and Billing for Colorectal Cancer Screening. Medicare covers High Risk Screening Colonoscopies in the following situations:
  • A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
  • A family history of adenomatous polyposis;<
  • A family history of hereditary nonpolyposis colorectal cancer;
  • A personal history of adenomatous polyps;
  • A personal history of colorectal cancer;
  • A personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis.
MLN Matters SE0613 This policy for Diagnostic and Therapeutic Colonoscopy includes the following excerpt:
  • Surveillance of colonic neoplasia:
    • Evaluation of the entire colon for a cancer or polyps in a patient with treatable cancer or with polyps noted on an earlier colonoscopy in accordance with the established national guidelines.
    • This includes patients with known polyps from a previous colonoscopy or imaging study who have a known genetic predisposition for colon cancer.
Is this section only talking about patients who have current known polyps or is it also referring to patients with a personal history of polyps?		 This policy deals with diagnostic and therapeutic colonoscopy and does not address screening colonoscopy. In response to the question surveillance diagnostic/therapeutic colonoscopy may be done with either current or history of the presence of polyps adhering to the specialty society guidelines.
Last Updated Dec 09 , 2023