LCD for CT Colonography (Virtual Colonoscopy) (L23478)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L23478 

 

LCD Title 

CT Colonography (Virtual Colonoscopy) 

 

Contractor's Determination Number 

L23478 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

Title XVIII of the Social Security Act (SSA), Section 1862(a)(7), excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A), allows coverage and payment for only those services considered medically reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833(e), prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations (CFR), Title 42, part 410.32, specifies that all diagnostic tests must be ordered by a provider who is the treating provider for the patient and who will use the test in the patient’s care.

CFR, Title 42, part 410.37, subpart B, designates the tests approved for coverage of colorectal cancer screening.

CMS Manual System, Publication 100-08, Program Integrity Manual, Chapter 3, Section 3.4, Additional Documentation Requests, indicates that Medicare may request documentation from referring (treating) physicians as part of Medical Review of claims in prepay or postpay settings. See Appendix.
 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 09/30/2006  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

 

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Indications of Coverage

CT
colonography, also known as CT virtual colonoscopy, utilizes
helical computed tomography of the abdomen and pelvis to visualize the colon lumen, along with 3-D reconstruction. The test requires colonic preparation similar to that required for standard colonoscopy (instrument colonoscopy), and air insufflation to achieve colonic distention.

INDICATIONS:


Diagnostic CT colonography is indicated for patients in whom a prior instrument colonoscopy of
the entire colon was incomplete because the colonoscope could not be passed through the entire colon.

Virtual colonoscopy should be performed soon after the failed colonoscopy so that the patient
will not have to endure repeat colonic preparation.

The unsuccessful instrument colonoscopy does not need to have been perform
ed for medically necessary (e.g. non-screening) reasons, however the purpose for the virtual colonography must be to replace a diagnostic colonoscopy being performed for medically necessary (non-screening) reasons. The virtual colonoscopy will be considered to be not medically necessary when followed by a therapeutic (e.g. excisional) colonoscopy.


Limitations of Coverage

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. CT colonography is not among the designated options in the Medicare benefit for colon screening.

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, except in the instance where a prior colonoscopy was incomplete and there is no reason to believe an instrument colonoscopy would be any more successful at the current time.

Since CT colonography with abnormal or suspicious findings would require a subsequent instrument colonoscopy for diagnosis (e.g., biopsy) or for treatment (e.g., polypectomy), virtual colonoscopy is not reimbursable when used as an adjunct to further define findings on an instrument colonoscopy, even though performed for signs or symptoms of disease.
 

 

Coverage Topic 

Diagnostic Tests and X-Rays
 

 

Coding Information

Bill Type Codes: 

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.

12x

Hospital-inpatient or home health visits (Part B only)

13x

Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

14x

Non-Patient Laboratory Specimens

85x

Special facility or ASC surgery-rural primary care hospital (eff 10/94)

 

 

Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0750

Gastro-intestinal services-general classification

 

 

CPT/HCPCS Codes 

 

0067T

COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY (IE, VIRTUAL COLONOSCOPY); DIAGNOSTIC

Virtual colonography is not covered for screening.

0066T

COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY (IE, VIRTUAL COLONOSCOPY); SCREENING

 

 

ICD-9 Codes that Support Medical Necessity 

The primary determinants of medical necessity are those presented in the Indications and Limitations of Coverage section above. The ICD-9-cm codes listed below are not stand-alone justifications of medical necessity.

009.0 - 009.3

INFECTIOUS COLITIS ENTERITIS AND GASTROENTERITIS - DIARRHEA OF PRESUMED INFECTIOUS ORIGIN

014.00 - 014.06

TUBERCULOUS PERITONITIS UNSPECIFIED EXAMINATION - TUBERCULOUS PERITONITIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

014.80 - 014.86

OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS UNSPECIFIED EXAMINATION - OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

153.0 - 153.9

MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

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

158.8

MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM

195.3

MALIGNANT NEOPLASM OF PELVIS

196.2

SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA-ABDOMINAL LYMPH NODES

197.5 - 197.7

SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM - MALIGNANT NEOPLASM OF LIVER SECONDARY

199.0

DISSEMINATED MALIGNANT NEOPLASM

211.3

BENIGN NEOPLASM OF COLON

211.4

BENIGN NEOPLASM OF RECTUM AND ANAL CANAL

230.3 - 230.6

CARCINOMA IN SITU OF COLON - CARCINOMA IN SITU OF ANUS UNSPECIFIED

235.2

NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM

235.5

NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED DIGESTIVE ORGANS

259.2

CARCINOID SYNDROME

263.0

MALNUTRITION OF MODERATE DEGREE

280.9

IRON DEFICIENCY ANEMIA UNSPECIFIED

285.1

ACUTE POSTHEMORRHAGIC ANEMIA

421.0

ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS

448.0

HEREDITARY HEMORRHAGIC TELANGIECTASIA

555.1

REGIONAL ENTERITIS OF LARGE INTESTINE

555.2

REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE

557.0

ACUTE VASCULAR INSUFFICIENCY OF INTESTINE

557.1

CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE

557.9

UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE

558.1

GASTROENTERITIS AND COLITIS DUE TO RADIATION

558.2

TOXIC GASTROENTERITIS AND COLITIS

558.9

OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS

560.0 - 560.2

INTUSSUSCEPTION - VOLVULUS

560.30

IMPACTION OF INTESTINE UNSPECIFIED

560.39

OTHER IMPACTION OF INTESTINE

560.81

INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) (POSTINFECTION)

560.89

OTHER SPECIFIED INTESTINAL OBSTRUCTION

560.9

UNSPECIFIED INTESTINAL OBSTRUCTION

562.10 - 562.13

DIVERTICULOSIS OF COLON (WITHOUT HEMORRHAGE) - DIVERTICULITIS OF COLON WITH HEMORRHAGE

564.4

OTHER POSTOPERATIVE FUNCTIONAL DISORDERS

564.5

FUNCTIONAL DIARRHEA

564.7

MEGACOLON OTHER THAN HIRSCHSPRUNG'S

564.81

NEUROGENIC BOWEL

564.89

OTHER FUNCTIONAL DISORDERS OF INTESTINE

569.0

ANAL AND RECTAL POLYP

569.3

HEMORRHAGE OF RECTUM AND ANUS

569.41

ULCER OF ANUS AND RECTUM

569.81 - 569.86

FISTULA OF INTESTINE EXCLUDING RECTUM AND ANUS - DIEULAFOY LESION (HEMORRHAGIC) OF INTESTINE

569.89

OTHER SPECIFIED DISORDERS OF INTESTINES

578.1

BLOOD IN STOOL

578.9

HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED

701.2

ACQUIRED ACANTHOSIS NIGRICANS

759.6

OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED

787.91

DIARRHEA

787.99

OTHER SYMPTOMS INVOLVING DIGESTIVE SYSTEM

789.00 - 789.07

ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN GENERALIZED

789.09

ABDOMINAL PAIN OTHER SPECIFIED SITE

792.1

NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS

793.4

NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT

936

FOREIGN BODY IN INTESTINE AND COLON

 

 

Diagnoses that Support Medical Necessity 

Any diagnosis consistent with those specified in the Indications and Limitations of Coverage and/or Medical Necessity section or the ICD-9-CM descriptors in the ICD-9-CM Codes That Support Medical Necessity section. 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

 

V10.00

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN GASTROINTESTINAL TRACT

V10.05

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE

V10.06

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

V10.09

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN GASTROINTESTINAL TRACT

V12.70

PERSONAL HISTORY OF UNSPECIFIED DIGESTIVE DISEASE

V12.72

PERSONAL HISTORY OF COLONIC POLYPS

V12.79

PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM DISEASES

V16.0

FAMILY HISTORY OF MALIGNANT NEOPLASM OF GASTROINTESTINAL TRACT

V72.5

RADIOLOGICAL EXAMINATION NOT ELSEWHERE CLASSIFIED

V76.41

SCREENING FOR MALIGNANT NEOPLASMS OF THE RECTUM

V76.51

SPECIAL SCREENING FOR MALIGNANT NEOPLASMS COLON

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

Any diagnosis inconsistent with the Indications and Limitations of Coverage and/or Medical Necessity section, or the ICD-9-CM descriptors in the ICD-9-CM Codes That Support Medical Necessity section. 

 

General Information

Documentation Requirements 

As defined in the "reasonable and necessary" clauses that are contained in Section 1862 (a)(1)(A) of Title XVIII, of the (SSA), it is expected that supportive documentation evidencing the condition and treatment will be documented in the medical record and be available upon request.

Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-9-CM codes will be returned as unprocessable.

The results of an instrument colonoscopy performed prior to the CT colonography which was incomplete must be retained in the patient’s medical record.

The order/prescription from the referring physicians must be retained in the patient’s medical record.
 

 

Appendices 

 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

LCDs from NHIC, AdminaStar, Arkansas BCBST, Cahaba, CIGNA, Empire, Kansas BCBS, Palmetto

CareFirst Blue Cross and Blue Shield of Maryland Medicare Coverage Database article #A14699

Cotton, PB et al, “Computed Tomographic Colonography (Virtual Colonoscopy)”, JAMA 291:1713-1719 (April 14, 2004)

Fenlon,HM et al, “Occlusive Colon Carcinoma: Virtual Colonoscopy in the Preoperative Evaluation of the Proximal Colon”, Radiology 210: 423-428 (February 1999)

Johnson, CD et al, “Prospective BlindedComparison of CT Colonography and Double Contrast Barium Enema fo Screen-Detection of Colorectal Polyps”, abstract Abdominal Radiology course 2003, The 32nd Annual Postgraduate Course and Scientific Meeting of The Society of Gastrointestinal Radiologists and the 28th Scientific Assembly of The Society of Uroradiology

Laghi, A et al, “Detection of colorectal lesions with virtual computed tomographic colonoscopy” Am J Surgery 183: 124-131 (2002)

Laghi, A et al, “Computed Tomographic Colonography (Virtual Colonoscopy): Blinded Prospective Comparison with Conventional Colonoscopy for the Detection of Colorectal Neoplasia” Endoscopy 34:441-446 (2002)

Macari M, Megibow AJ, Berman P, Milano A, Dicker M. CT colonography in patients with failed colonoscopy. AJR 1999;173:561-564

Morrin,MM et al, “Endoluminal CT Colonography After an Incomplete Endoscopic Colonoscopy”, AJR 172: 913-918 (April 1999)

Morrin MM, Farrell RJ, Raptopoulos V, et al. Role of virtual computed tomographic colonography in patients with colorectal cancers and obstructing colorectal lesions. Diseases of the Colon and Rectum 2000;43:303-311.

Neri E, Giusti P, Battolla L, Vagli P, Boraschi P, Lencioni R, et. al.
Colorectal cancer: role of CT colonography in preoperative evaluation after incomplete colonoscopy. Radiology 2002; 223:615-619.

Pickhardt, PJ et al, “Computed Tomographic Virtual Colonoscopy to Screen for Colorectal Neoplasia in Asymptomatic Adults” NEJM 349(23):2191-2200 (December 4, 2003)

Ransohoff, DF, Virtual Colonoscopy – “What It Can Do vs What It Will Do” JAMA 291:1772-1774 (April 14, 2004)

2005 ICD-9-CM, copyright 2004, Ingenix, Inc.

2005 Current Procedural Terminology (CPT), copyright 2004, American Medical Association

AMA Press, CPT Changes 2005, page 220, presents CT colonography as including 3D reconstruction. CPT Changes is not an official Medicare reference, unlike the CPT manual itself. However, most interpretations are consistent with clinical practice and NHIC considers CT colonography to include 3D reconstruction.
 

 

Advisory Committee Meeting Notes 

This policy was presented to the FIAC electronically. There were no comments on this policy. 

 

Start Date of Comment Period 

06/30/2006 

 

End Date of Comment Period 

08/15/2006 

 

Start Date of Notice Period 

08/16/2006 

 

Revision History Number 

R1 

 

Revision History Explanation 

R1 Released to Notice 08/16/2006

10/30/2007 - review with no changes 

 

Reason for Change 

Other
 

Last Reviewed On Date 

10/30/2007 

 

Related Documents 

This LCD has no Related Documents.

 

LCD Attachments 

Comment and Response - Comment and Response (3,274 bytes)