SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

Noridian Administrative Services, LLC
Contractor Number ^{back to top}
00820
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L23717

LCD Title ^{back to top}
CT Colonography

Contractor's Determination Number ^{back to top}
B2007.30

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 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 ^{back to top}
Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary. Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim. Medicare Benefit Policy Manual 100-02, Chapter 15, Section 280.2 Medicare National Coverage Determinations Manual 100-3, Chapter 1, Part 4, Section 210.3. Medicare Claims Processing Manual 100-4, Chapter 18, Section 60. Code of Federal Regulations (CFR), Title 42, part 410.37, subpart B

Primary Geographic Jurisdiction ^{back to top}
Colorado

Oversight Region ^{back to top}
Region X

Original Determination Effective Date ^{back to top}
For services performed on or after 04/01/2007

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 04/01/2007

Revision Ending Date ^{back to top}
12/31/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Computed tomographic (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 fiberoptic colonoscopy, and air insufflation to achieve colonic distention. CT colonography is indicated only in patients having the following qualifying conditions: ● instrument colonoscopy of the entire colon is incomplete and/or contraindicated due to colon obstruction, ● coagulopathy, ● lifetime anticoagulation or long-term anticoagulation therapy with increased patient risk if discontinued, ● significant medical or surgical complications from previous standard colonoscopy. CT colonography is not a covered service when utilized in preoperative cancer staging, and in this clinical situation NAS believes that standard CT or MRI is the preferred imaging study. Patient personal preference or patient refusal to undergo colonoscopy, in the absence of one of the qualifying conditions noted above, even if signs or symptoms of colon disease are present, is not a covered indication for CT colonography. CPT Code 0066T (Computed tomographic (CT) colonography (i.e., virtual colonoscopy); screening) is never payable, as this service is not a part of the colorectal cancer screening benefit per the Medicare Benefit Policy Manual 100-02, Chapter 15, Section 280.2. Screening CT colonography is not reimbursable when used as an alternative to fiberoptic colonoscopy in the absence of signs or symptoms of disease, regardless of family history or other risk factors for the development of colonic disease. (Code of Federal Regulations (CFR), Title 42, part 410.37, subpart B.) This section designates the only tests approved by CMS for coverage of colorectal cancer screening and does not include CT colonography). Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.

Coding Information

Bill Type Codes: ^{back to top}

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.

999x	Not Applicable

Revenue Codes: ^{back to top}

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.

99999 Not Applicable

CPT/HCPCS Codes ^{back to top}

0067T COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY (IE, VIRTUAL COLONOSCOPY); DIAGNOSTIC

ICD-9 Codes that Support Medical Necessity ^{back to top}

Note: Diagnosis codes are based on the current ICD-9-CM codes that are effective at the time of LCD publication. Any updates to ICD-9-CM codes will be reviewed by NAS, and coverage should not be presumed until the results of such review have been published/posted.

This is the only covered ICD-9-CM code that support medical necessity for the CPT code 0067T:

V49.89* OTHER SPECIFIED CONDITIONS INFLUENCING HEALTH STATUS

*V49.89
For this LCD only, use this code only when the patient has one of the following qualifying conditions:
Instrument colonoscopy of the entire colon is incomplete and/or contraindicated due to colon obstruction
Coagulopathy
Lifetime anticoagulation or long-term anticoagulation therapy with increased patient risk if discontinued
Significant medical or surgical complications from previous standard colonoscopy.

Diagnoses that Support Medical Necessity ^{back to top}

All diagnoses listed in ICD-9-CM Codes that Support Medical Necessity above.

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

All diagnoses not listed in ICD-9-CM Codes that Support Medical Necessity above.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

All diagnoses not listed in ICD-9-CM Codes that Support Medical Necessity above.

General Information

Documentation Requirements ^{back to top}

Documentation must support the medical necessity of this service as outlined in the Indications and Limitations of Coverage and/or Medical Necessity section of this policy.

Documentation in the patient's medical record should include all of the following:

1. A current, pertinent history and physical examination, and progress notes describing and supporting the covered indication

2. Pertinent prior diagnostic testing and completed report(s). This would include, when appropriate, the results of a standard colonoscopy, performed prior to the CT colonography, which was incomplete due to an inability to pass the colonoscope proximally secondary to an obstructing neoplasm, stenosis, spasm, redundant colon, diverticulitis, extrinsic compression, or aberrant anatomy/scarring from prior surgery.

3. The order/prescription or written request from the referring physician.

The medical record must be made available to Medicare upon request.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision ^{back to top}

● Cotton, Peter B. et al Computed Tomographic Colonography (Virtual Colonoscopy): A Multicenter Comparison With Standard Colonoscopy for Detection of Colorectal Neoplasia; JAMA 291: 1713-1719, April 14, 2004.
● Ransohoff, David F. Virtual Colonoscopy-What It Can Do vs What It Will Do; JAMA 291: 1772-1774, April 14, 2004.
● Abeloff Clinical Oncology; 3rd Edition, 2004
● Feldman, Sleisenger and Fordtran’s Gastrointestinal and Liver Disease; 7th Edition, 2002
● Dachman AH Virtual Colonoscopy: Past, Present, and Future; Radiol Clin North Am; 01 March 2003; 41(2); 377-93; from MIH/HLM Medline
● Isenberg GA Virtual Colonoscopy; Gastrointest Endosc; 01 Apr 2003; 187(4): 57(4); 451-4; from NIH/NLM Medline
● Serracino-Inglott F Early experiences with computed axial tomography colonography; Am J Surg; 01 Apr 2004; 187(4): 511-4
● Nease D Colorectal cancer screening; Clin Fam Pract; 2004 Sep; 6(3); 693
● Other carriers’ policies
● NAS Carrier Advisory Committee members

Advisory Committee Meeting Notes ^{back to top}

This medical policy was presented at the Medicare Part B Open Public Meeting held on September 12, 2006 and discussed at the following Carrier Advisory Committee meetings:

Alaska - September 28, 2006
Colorado - October 19, 2006
Hawaii - October 20, 2006
Iowa - October 5, 2006
Nevada - October 19, 2006
Oregon - October 14, 2006
Washington - October 10, 2006

This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies.

The Section titled "Does the ‘CPT 30% Rule' apply?" needs clarification. This rule comes from the AMA (American Medical Association), the organization that holds the copyrights for all CPT codes. The rule states that if, in a given section (e.g., surgery) or subsection (e.g., surgery, integumentary) of the CPT Manual, more than 30% of the codes are listed in the LCD, then the short descriptors must be used rather than the long descriptors found in the CPT Manual.

This policy is subject to the reasonable and necessary guidelines and the limitation of liability provision.

This medical policy consolidates and replaces all previous policies and publications on this subject by NAS and its predecessors for Medicare Part B.

Medicare Coverage Database

LCD for CT Colonography (L23717)