Coverage Indications, Limitations, and/or Medical Necessity
Indications
CT colonography, also known as virtual colonoscopy, utilizes helical computed tomography of the abdomen and pelvis to visualize the colon lumen, along with 2D or 3D reconstruction. The test requires colonic preparation similar to that required for instrument colonoscopy, and air insufflation to achieve colonic distention.
CT colonography is only indicated:
1. In those patients in whom an instrument colonoscopy of the entire colon is incomplete due to an inability to pass the colonoscope proximally, due to one of the following:
A. An impassable obstruction (e.g., neoplasm, intrinsic compression, stenosis due to causes such as inflammatory bowel disease)
B. Scarring or aberrant anatomy (e.g., stricture, tortuosity, adhesion) with obstruction from prior surgery, radiation, diverticular disease, etc.
C. Extrinsic compression
This is intended for use in pre-operative situations when knowledge of the unvisualized colon proximal to the obstruction would be of use to the surgeon in planning the operative approach to the patient.
2. When ordering physician determines and documents instrument colonoscopy cannot be safely attempted based on current or previous studies. Such contraindications may include severe coagulopathy, increased sedation risk, etc.
Limitations
1. CT colonography is not reimbursable when used for screening, or in the absence of signs or symptoms of disease, regardless of family history or other risk factors for the development of colonic disease.
2. CT colonography is not reimbursable when used as an alternative to instrument colonoscopy for screening or in the absence of signs or symptoms of disease.
3. CT colonography is not reimbursable following incomplete colonoscopy if the reason for the colonoscopy is other than one of those described above.
4. Except as noted in Indication 1. a., CT colonography is not indicated in patients with high risk disease symptoms (e.g. inflammatory bowel disease, hematochezia) and situations in which the pretest probability of identification of colonic abnormality is increased.
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
74261 Ct colonography dx
74262 Ct colonography dx w/dye
Group 2 Paragraph: The following CPT code is not covered by Medicare:
Group 2 Codes:
74263 Ct colonography screening
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph: The correct use of an ICD-9-CM code listed in the "ICD-9 codes that Support Medical Necessity" section does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this LCD.
ICD-9 codes must be coded to the highest level of specificity. Consult the ‘Official ICD-9-CM Guidelines for Coding and Reporting’ in the current ICD-9-CM book for correct coding guidelines. This LCD does not take precedence over the Correct Coding Initiative (CCI).
For CPT Codes 74261 and 74262:
Group 1 Codes:
153.0 - 153.3
MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF SIGMOID COLON
153.6 MALIGNANT NEOPLASM OF ASCENDING COLON
153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE
154.0 - 154.3
MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION - MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE
154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS
211.3 BENIGN NEOPLASM OF COLON
211.4 BENIGN NEOPLASM OF RECTUM AND ANAL CANAL
560.0 - 560.9
INTUSSUSCEPTION - UNSPECIFIED INTESTINAL OBSTRUCTION
562.11 DIVERTICULITIS OF COLON (WITHOUT HEMORRHAGE)
562.13 DIVERTICULITIS OF COLON WITH HEMORRHAGE
V64.3* PROCEDURE NOT CARRIED OUT FOR OTHER REASONS
V67.1 FOLLOW-UP EXAMINATION FOLLOWING RADIOTHERAPY
Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: **NOTE: V64.3 is to be used for Indication #2.
ICD-9 Codes that DO NOT Support Medical Necessity
Paragraph: Any ICD-9 code that is not listed in the "ICD-9 codes that Support Medical Necessity" section of this LCD.
Tags:
CPT / DX denial