Article - Billing and Coding: Computed Tomographic (CT) Colonography for Diagnostic Uses (A57026)

CMS National Coverage PolicyLanguage quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).42 CFR Section 410.38, subpart B indicates the tests approved for coverage of colorectal cancer screeningCMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Chapter 1:220.1 Computed TomographyCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15:80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 13:10 ICD-9-CM Coding for Diagnostic Tests20 Payment Conditions for Radiology Services80 Supervision and Interpretation (S & I) Codes and Interventional RadiologyArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Computed Tomographic (CT) Colonography for Diagnostic Uses.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Utilization Guidelines:CT colonography is reimbursable only when performed following an instrument colonoscopy which was incomplete or when a board certified or board eligible gastroenterologist or surgeon trained in endoscopy determined from an evaluation of the patient that optical colonoscopy can not be safely attempted. Tests performed without a prior incomplete instrument colonoscopy in history or documentation by a board certified or eligible gastroenterologist, a surgeon trained in endoscopy or a physician with equivalent endoscopic training indicating why an optical colonoscopy cannot be safely attempted will be denied.