(Medicare Claims Processing Manual)

60.3 - Determining High Risk for Developing Colorectal Cancer  (Rev. 12435, Issued:12- 28-23, Effective:01- 29-24, Implementation:01- 29-24)  A. Characteristics of the High Risk Individual   An individual at high risk for developing colorectal cancer has one or more of the following:    A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;    A family history of familial adenomatous polyposis;    A family history of hereditary nonpolyposis colorectal cancer;    A personal history of adenomatous polyps;    A personal history of colorectal cancer; or    Inflammatory bowel disease, including Crohns Disease, and ulcerative colitis.    B. Partial List of ICD -10-CM Codes Indicating High Risk   Listed below are some examples of diagnoses that meet the high -risk criteria for colorectal cancer.  This is not an all -inclusive list.  There may be more instances of conditions, which may be coded and could be considered high risk at the medical director s discretion.    Partial List of diagnosis codes indicating high risk: only applicable to G0105 and G0120 (high risk colorectal cancer screening)   C18.0  Malignant neoplasm of cecum  C18.2  Malignant neoplasm of ascending colon  C18.3  Malignant neoplasm of hepatic flexure  C18.4  Malignant neoplasm of transverse colon  C18.5  Malignant neoplasm of splenic flexure  C18.6  Malignant neoplasm of descending colon  C18.7  Malignant neoplasm of sigmoid colon C18.8  Malignant neoplasm of overlapping sites of colon  C19   Malignant neoplasm of rectosigmoid junction C20   Malignant neoplasm of rectum  C21.0  Malignant neoplasm of anus, unspecified  C21.1  Malignant neoplasm of anal canal  C21.2  Malignant neoplasm of cloacogenic zone  C21.8  Malignant neoplasm of overlapping sites of rectum, anus and anal canal  C49.A3  Gastrointestinal stromal tumor of small intestine  C49.A4  Gastrointestinal stromal tumor of large intestine  C49.A5  Gastrointestinal stromal tumor of rectum  C78.5  Secondary malignant neoplasm of large intestine and rectum  C7A.021  Malignant carcinoid tumor of the cecum  C7A.022  Malignant carcinoid tumor of the ascending colon  C7A.023  Malignant carcinoid tumor of the transverse colon C7A.024  Malignant carcinoid tumor of the descending colon C7A.025  Malignant carcinoid tumor of the sigmoid colon C7A.026  Malignant carcinoid tumor of the rectum  D01.0  Carcinoma in situ of colon D01.1  Carcinoma in situ of rectosigmoid junction  D01.2  Carcinoma in situ of rectum  D01.3  Carcinoma in situ of anus and anal canal  D12.0  Benign neoplasm of cecum  D12.2  Benign neoplasm of ascending colon D12.3  Benign neoplasm of transverse colon  D12.4  Benign neoplasm of descending colon D12.5  Benign neoplasm of sigmoid colon D12.7  Benign neoplasm of rectosigmoid junction  D12.8  Benign neoplasm of rectum  D12.9  Benign neoplasm of anus and anal canal  D37.4  Neoplasm of uncertain behavior of colon D37.5  Neoplasm of uncertain behavior of rectum  D37.9  Neoplasm of uncertain behavior of digestive organ, unspecified  D3A.021  Benign carcinoid tumor of the cecum  D3A.022  Benign carcinoid tumor of the ascending colon  D3A.023  Benign carcinoid tumor of the transverse colon  D3A.024  Benign carcinoid tumor of the descending colon  D3A.025  Benign carcinoid tumor of the sigmoid colon D3A.026  Benign carcinoid tumor of the rectum  D3A.029  Benign carcinoid tumor of the large intestine, unspecified portion  K50.00  Crohn's disease of small intestine without complications  K50.011  Crohn's disease of small intestine with rectal bleeding  K50.012  Crohn's disease of small intestine with intestinal obstruction  K50.013  Crohn's disease of small intestine with fistula  K50.014  Crohn's disease of small intestine with abscess  K50.018  Crohn's disease of small intestine with other complication  K50.019  Crohn's disease of small intestine with unspecified complications  K50.10  Crohn's disease of large intestine without complications  K50.111  Crohn's disease of large intestine with rectal bleeding K50.112  Crohn's disease of large intestine with intestinal obstruction K50.113  Crohn's disease of large intestine with fistula  K50.114  Crohn's disease of large intestine with abscess  K50.118  Crohn's disease of large intestine with other complication K50.119  Crohn's disease of large intestine with unspecified complications  K50.80  Crohn's disease of both small and large intestine without complications  K50.811  Crohn's disease of both small and large intestine with rectal bleeding  K50.812  Crohn's disease of both small and large intestine with intestinal                                                    obstruction K50.813  Crohn's disease of both small and large intestine with fistula  K50.814  Crohn's disease of both small and large intestine with abscess  K50.818  Crohn's disease of both small and large intestine with other complication K50.819  Crohn's disease of both small and large intestine with unspecified complications  K50.90  Crohn's disease, unspecified, without complications  K50.911  Crohn's disease, unspecified, with rectal bleeding K50.912  Crohn's disease, unspecified, with intestinal obstruction K50.913  Crohn's disease, unspecified, with fistula  K50.914  Crohn's disease, unspecified, with abscess  K50.918  Crohn's disease, unspecified, with other complication K50.919  Crohn's disease, unspecified, with unspecified complications  K51.00  Ulcerative (chronic) pancolitis without complications  K51.011  Ulcerative (chronic) pancolitis with rectal bleeding  K51.012  Ulcerative (chronic) pancolitis with intestinal obstruction  K51.013  Ulcerative (chronic) pancolitis with fistula  K51.014  Ulcerative (chronic) pancolitis with abscess  K51.018  Ulcerative (chronic) pancolitis with other complication  K51.019  Ulcerative (chronic) pancolitis with unspecified complications  K51.20  Ulcerative (chronic) proctitis without complications  K51.211  Ulcerative (chronic) proctitis with rectal bleeding  K51.212  Ulcerative (chronic) proctitis with intestinal obstruction  K51.213  Ulcerative (chronic) proctitis with fistula  K51.214  Ulcerative (chronic) proctitis with abscess  K51.218  Ulcerative (chronic) proctitis with other complication  K51.219  Ulcerative (chronic) proctitis with unspecified complications  K51.30  Ulcerative (chronic) rectosigmoiditis without complications  K51.311  Ulcerative (chronic) rectosigmoiditis with rectal bleeding  K51.312  Ulcerative (chronic) rectosigmoiditis with intestinal obstruction  K51.313  Ulcerative (chronic) rectosigmoiditis with fistula  K51.314  Ulcerative (chronic) rectosigmoiditis with abscess  K51.318  Ulcerative (chronic) rectosigmoiditis with other complication  K51.319  Ulcerative (chronic) rectosigmoiditis with unspecified complications  K51.40  Inflammatory polyps of colon without complications  K51.411  Inflammatory polyps of colon with rectal bleeding  K51.412  Inflammatory polyps of colon with intestinal obstruction K51.413  Inflammatory polyps of colon with fistula  K51.414  Inflammatory polyps of colon with abscess  K51.418  Inflammatory polyps of colon with other complication K51.419  Inflammatory polyps of colon with unspecified complications  K51.50  Left sided colitis without complications  K51.511  Left sided colitis with rectal bleeding  K51.512  Left sided colitis with intestinal obstruction  K51.513  Left sided colitis with fistula  K51.514  Left sided colitis with abscess  K51.518  Left sided colitis with other complication  K51.519  Left sided colitis with unspecified complications  K51.80  Other ulcerative colitis without complications  K51.811  Other ulcerative colitis with rectal bleeding  K51.812  Other ulcerative colitis with intestinal obstruction  K51.813  Other ulcerative colitis with fistula  K51.814  Other ulcerative colitis with abscess  K51.818  Other ulcerative colitis with other complication  K51.819  Other ulcerative colitis with unspecified complications  K51.90  Ulcerative colitis, unspecified, without complications  K51.911  Ulcerative colitis, unspecified with rectal bleeding  K51.912  Ulcerative colitis, unspecified with intestinal obstruction  K51.913  Ulcerative colitis, unspecified with fistula  K51.914  Ulcerative colitis, unspecified with abscess  K51.918  Ulcerative colitis, unspecified with other complication  K51.919  Ulcerative colitis, unspecified with unspecified complications  K52.1  Toxic gastroenteritis and colitis  K52.89  Other specified non- infective gastroenteritis and colitis  K52.9  Non-infective gastroenteritis and colitis, unspecified  K57.20  Diverticulitis of large intestine with perforation and abscess without bleeding  K57.21  Diverticulitis of large intestine with perforation and abscess with bleeding  K57.30  Diverticulosis of large intestine without perforation or abscess without bleeding K57.31  Diverticulosis of large intestine without perforation or abscess with bleeding  K57.32  Diverticulitis of large intestine without perforation or abscess without bleeding  K57.33  Diverticulitis of large intestine without perforation or abscess with bleeding  K57.40  Diverticulitis of both small and large intestine with perforation and abscess                            without bleeding  K57.41  Diverticulitis of both small and large intestine with perforation and abscess with                          bleeding K57.50  Diverticulosis of both small and large intestine without perforation or abscess                           without bleeding  K57.51  Diverticulosis of both small and large intestine without perforation or abscess                          with bleeding K57.52  Diverticulitis of both small and large intestine without perforation or abscess                          without bleeding  K57.53  Diverticulitis of both small and large intestine without perforation or abscess with                           bleeding K57.80  Diverticulitis of intestine, part unspecified, with perforation and abscess without                           bleeding K57.81  Diverticulitis of intestine, part unspecified, with perforation and abscess with                          bleeding K57.90  Diverticulosis of intestine, part unspecified, without perforation or abscess                          without bleeding  K57.91  Diverticulosis of intestine, part unspecified, without perforation or abscess with                          bleeding K57.92  Diverticulitis of intestine, part unspecified, without perforation or abscess without                          bleeding K57.93  Diverticulitis of intestine, part unspecified, without perforation or abscess with