(Medicare Benefit Policy Manual)

 Chronic Digestive Disease Condition   o 555.0 -  Regional enteritis of small intestine  o 555.1 -  Regional enteritis of large intestine  o 555.2 -  Regional enteritis of small intestine with large intestine  o 555.9 -  Regional enteritis of unspecified site  o 556.0 -  Ulcerative (chronic) enterocolitis  o 556.1 -  Ulcerative (chronic) ileocolitis  o 556.2 -  Ulcerative (chronic) proctitis  o 556.3 -  Ulcerative (chronic) proctosigmoiditis  o 556.8 -  Other ulcerative colitis  o 556.9 -  Ulcerative colitis, unspecified (nonspecific PDX on the MCE)    Inflammatory Bowel   o 558.2 -  Toxic gastroenteritis and colitis  o 558.9 -  Other and unspecified noninfectious gastroenteritis and colitis   C.  Partial List of ICD -10-CM Codes Indicating High Risk (for Services after Implementation of ICD -10)  Code  Description  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  Code  Description  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  K51.80  Other  ulcerative  colitis  without  complications  K51.80  Other  ulcerative  colitis  without  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  K51.80  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  Code  Description  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 noninfective gastroenteritis and colitis  K52.9  Noninfective gastroenteritis and colitis, unspecified  Z85.038  Personal history of other malignant neoplasm of large intestine  Z85.048  Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus  D12.6  Benign neoplasm of colon, unspecified  Z12.11  Encounter for screening for malignant neoplasm of colon  Z12.12  Encounter for screening for malignant neoplasm of rectum  Z15.09  Genetic susceptibility to other malignant neoplasm  Z80.0  Family history of malignant neoplasm of digestive organs  Z83.71  Family history of colonic polyps   280.2.4 - Determining Frequency Standards  (Rev. 1, 10- 01-03) B3-4180.4  To determine the 11, 23, 47, and 119- month periods, the count starts beginning with the month after the month in which a previous test/procedure was performed.   EXAMPLE:  The beneficiary received a fecal -occult blood test in January 2000.  The A/B MAC (B) starts its count beginning with February 2000.  The beneficiary is eligible to receive another blood test in January 2001 (the month after 11 full months have passed).   280.2.5 - Noncovered Services  (Rev. 1, 10- 01-03) B3-4180.5  The following noncovered HCPCS codes are used to allow claims to be billed and denied for beneficiaries who need a Medicare denial for other insurance purposes for the dates of service indicated:   A.  From January 1, 1998 Through June 30, 2001, Inclusive  Code G0121 (colorectal cancer screening; colonoscopy on an individual not meeting criteria for high risk) should be used when this procedure is performed on a beneficiary who does NOT meet the criteria for high risk.  This service should be denied as noncovered because it fails to meet the requirements of the benefit for these dates of service.  The beneficiary is liable for payment. Note that this code is a covered service for dates of service on or after July 1, 2001.  B.  On or After January 1, 1998  Code G0122 (colorectal cancer screening; barium enema) should be used when a screening barium enema is performed NOT as an alternative to either a screening colonoscopy (code G0105) or a screening flexible sigmoidoscopy (code G0104).  This service should be denied as noncovered because it fails to meet the requirements of the benefit.  The beneficiary is liable for payment.   280.3 - Screening Mammography (Rev. 1, 10-01-03) A3-3660.10, B3-4601.1  Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added 1834(c) of the Act to provide for Part B coverage of mammography screening performed on or after January 1, 1991. The term screening mammography means a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer and includes a physicians interpretation of the results of the procedure.  Unlike diagnostic mammographies, there do not need to be signs, symptoms, or history of breast disease in order for the exam to be covered.  A doctors prescription or referral is not necessary for the procedure to be covered.  Payment may be made for a screening mammography furnished to a woman at her direct request, and based on a womans age and statutory frequency parameter.  Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening mammographies for women over 39 and waives the Part B deductible.  Coverage applies as follows:  Age Screening Period  Less than 35 years old  No payment may be made for a screening mammography performed on a woman under 35 years of age. 35-39 (Baseline). Pay for only one screening mammography performed on a woman between her 35th and 40th birthday. Over age 39  For a woman over 39, pay for a screening mammography performed after 11 full months have passed following the month in which the last screening mammography was performed.  To determine the 11-month period, A/B MACs (A) and (B) start counting beginning with the month after the month in which a previous screening mammography was performed.  EXAMPLE:   If Mrs. Smith received a screening mammography examination in January 1998, begin counting the next month (February 1998) until 11 months have elapsed.  Payment can be made for another screening mammography in January 1999.  See the Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services, 30, for billing and payment instructions.  280.4 - Screening Pap Smears  (Rev. 194, Issued: 09-03-14, Effective: Upon Implementation of ICD-10, Implementation: Upon Implementation of ICD -10)  Effective, January 1, 1998, 4102 of the Balanced Budget Act (BBA) of 1997 (P.L. 105-33) amended 1861(nn) of the Act (42 USC 1395X(nn)) to include coverage every 3 years for a screening Pap smear or more frequent coverage for women:   1.  At high risk for cervical or vaginal cancer; or  2.  Of childbearing age who have had a Pap smear during any of the preceding 3 years indicating the presence of cervical or vaginal cancer or other abnormality.   Effective July 1, 2001, the Consolidated Appropriations Act of 2001 (P.L. 106-554) modifies 1861(nn) to provide Medicare coverage for biennial screening Pap smears.  Specifications for frequency limitations are defined below.  For claims with dates of service from January 1, 1998, through June 30, 2001, screening Pap smears are covered when ordered and collected by a doctor of medicine or osteopathy (as defined in 1861(r)(1) of the Act), or other authorized practitioner (e.g., a certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist, who is authorized under State law to perform the examination) under one of the following conditions.