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Screening colonoscopy prior authorization for colon polyps

Updated: May 23, 2023

Is Preauth Required? According to the American Society for Gastrointestinal Endoscopy ASGE Standards Practice Committee, Appropriate use of GI endoscopy, colonoscopy is generally indicated for the evaluation of an abnormality on barium enema or other imaging study that is likely to be clinically significant. Additionally, according to the Polyp Guideline: Diagnosis, Treatment, and Surveillance for Patients with Colorectal Polyps, patients who have had excision of a large sessile polyp should have a follow-up colonoscopy in 3-6 months. If residual polyp is present, it should be resected and another 3-6 month follow-up colonoscopy should be performed to check for completeness of resection. If complete resection is not possible after two or three examinations, the patient should be referred for surgical therapy. Preauthorization may be required for these indications. Will the claim be denied? A screening colonoscopy would be covered by Medicare for the evaluation of colon polyps. The indications listed in the policy include evaluation of an abnormality discovered on imaging, evaluation of unexplained gastrointestinal bleeding, unexplained iron deficiency anemia, and surveillance of colorectal neoplasia. Colonoscopy is indicated for the evaluation of colorectal polyps detected by various methods, and is the most accurate method for detecting polyps of all sizes. The claim would not be denied for this treatment and condition. When is the following treatment medically necessary for the condition specified? A screening colonoscopy will be considered medically necessary for the evaluation and excision of polyps detected by barium enema or flexible sigmoidoscopy, computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), and positron emission tomography (PET). It is also considered medically necessary for the evaluation and treatment of bleeding from lesions such as vascular anomalies, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy). What would make the following treatment considered medically necessary? A screening colonoscopy is considered medically necessary when there is a suspicion of colorectal cancer or an abnormality is discovered by a radiology examination that is consistent with a colonic lesion that is likely to be clinically significant. Additionally, a screening colonoscopy is medically necessary if an abnormal oncology colorectal screening or stool-based DNA test is detected, or there is unexplained gastrointestinal bleeding not from the rectum or a perianal source. What are the relevant codes for the treatment? The CPT/HCPCS code for a screening colonoscopy for colon polyps is G0105. Making copies or utilizing the content of the UB-04 Manual, including codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The diagnosis codes for colon polyps are Z85.038, Z85.048, or Z86.010. Payment for this procedure should be consistent with payment methodologies currently in place for complete screening colonoscopies, including those contained in 42 CFR 419.44(b). In situations where a critical access hospital (CAH) has elected payment Method II for CAH patients, payment should be consistent with payment methodologies currently in place. When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure.

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