Colonoscopy Screenings and Related Subsequent Diagnostic Procedures

In all UnitedHealthcare Medicare Advantage plans, a colonoscopy that begins as an in-network screening service is subject to the $0 screening cost-share regardless of whether a polyp is found and/or removed during the procedure.

Coding:

• Endoscopy codes G0104, G0121 or G0105 are used for screening colonoscopies. These continue to assess a $0 in-network cost-share per the Medicare preventive services coverage guidelines.

• CPT Code 45330 (and family codes) and CPT Code 45378 (and family codes) billed with modifier PT are used if a screening turns into a diagnostic procedure. These codes, when billed with the PT modifier, will assess the $0 in-network cost-share. If the colonoscopy service is billed without the PT modifier, the claim will be processed as a surgery and the applicable cost-share will apply.

• Providers may not bill both the screening and the diagnostic services when a screening colonoscopy turns into a diagnostic procedure. Only the diagnostic code with the PT modifier may be billed in these circumstances.

• If the screening service and subsequent diagnostic procedure is performed at an out-of-network facility, applicable cost-shares will be assessed.

Current Policy Statement

Health Net, Inc. considers colonoscopy medically necessary according to the guidelines set forth by the American Gastroenterological Association, the American Society of Colon & Rectal Surgeons, the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, the American College of Radiology, the National Comprehensive Cancer Network, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy for patients who meet any of the following indications:

Diagnostic Colonoscopy

1. Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as a filling defect or stricture.
2. Evaluation of unexplained gastrointestinal bleeding, such as:
** Hematochezia not thought to be from rectum or perianal source, especially if the patient is > 40 years old.
** Melena of unknown origin after an upper GI source has been excluded.
** Presence of fecal occult blood.
3. Unexplained iron deficiency anemia.
4. Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management.
5. Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., dehydration, weight loss).
6. Evaluation of acute colonic ischemia/ischemic bowel disease.
7. Evaluation of cytomegaloviral colitis in a patient with HIV infection
8. Evaluation of patient with Streptococcus bovis endocarditis.
9. Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source).
10. Marking a neoplasm for surgical localization.
11. Constipation with involuntary weight loss of > 10 lbs within 12 weeks, or continued constipation following 2 weeks of treatment with fiber, hyperosmotic agents or stool softeners.

Therapeutic Colonoscopy
1. Excision of colonic polyp(s).
2. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).
3. Foreign body removal.
4. Decompression of pseudo-obstruction of the colon (Ogilvie's syndrome).
5. Decompression of acute nontoxic megacolon.
6. Treatment of sigmoid volvulus.
7. Balloon dilation of stenotic lesions (e.g., anastomotic strictures).
8. Palliative treatment of stenosing or bleeding neoplasms (e.g., laser, electrocoagulation, stenting).


Screening Colonoscopy

Initial screening colonoscopy for colorectal cancer at 50 years of age for asymptomatic, average risk men and women. If negative, rescreen with any accepted modality1 in 10 years.

Note: Screening may begin age 45 for African Americans because of the higher incidence of colorectal cancer.

Health Net, Inc. considers colonoscopy not medically necessary for any of the following circumstances:

1. Chronic, stable, irritable bowel syndrome or chronic abdominal pain; there are unusual exceptions in which colonoscopy may be done once to rule out disease, especially if symptoms are unresponsive to therapy.

2. Acute limited diarrhea.

3. Hemorrhoids.

4. Bright red rectal bleeding in patients with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source

5. Metastatic adenocarcinoma of unknown primary site in the absence of colonic signs or symptoms when it will not influence management.

6. Routine follow-up of inflammatory bowel disease (except for cancer surveillance in chronic ulcerative colitis and Crohn's colitis).

7. Upper GI bleeding or melena with a demonstrated upper GI source.

8. Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease.

Relative contraindications to colonoscopy:

1. Toxic megacolon and fulminant colitis.

2. Peritonitis

3. Known or suspected colonic necrosis.

4. Documented acute severe diverticulitis / diverticular abscess.

5. Possible perforated viscus.

6. Severe coagulopathy, severe thrombocytopenia, severe neutropenia

7. History of radiation therapy for abdominal or pelvic cancer

8. History of abdominal or pelvic malignancy

9. Extensive adhesions from prior abdominal surgery

10. Pregnancy *

Note* - Colonoscopy is currently contraindicated during pregnancy because of inadequate data on safety but may be strongly considered for severe life-threatening colonic conditions such as suspected colon cancer, evaluation of a right-sided colonic mass, and uncontrolled severe right-colonic hemorrhage, and to guide segmental colectomy for urgent colonic surgery.

CPT Description


91010  Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report

91020 Gastric motility (manometric) studies

ICD 10  Code Description

K21.0 Gastro-esophageal reflux disease with esophagitis
K21.9 Gastro-esophageal reflux disease without esophagitis
K22.0 Achalasia of cardia
K30 Functional dyspepsia
K52.2 Allergic and dietetic gastroenteritis and colitis
K52.89 Other specified noninfective gastroenteritis and colitis
R11.0 Nausea
R11.10 Vomiting, unspecified
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.13 Vomiting of fecal matter
R11.14 Bilious vomiting
R11.2 Nausea with vomiting, unspecified
R12 Heartburn
R13.0 Aphagia
R13.10 Dysphagia, unspecified
R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase
R13.13 Dysphagia, pharyngeal phase
R13.14 Dysphagia, pharyngoesophageal phase
R13.19 Other dysphagia
R14.0 Abdominal distension (gaseous)
R14.1 Gas pain
R14.2 Eructation
R14.3 Flatulence
R15.0 Incomplete defecation
R15.1 Fecal smearing
R15.2 Fecal urgency
R15.9 Full incontinence of feces
R19.11 Absent bowel sounds
R19.12 Hyperactive bowel sounds
R19.15 Other abnormal bowel sounds
R19.2 Visible peristalsis
R19.4 Change in bowel habit
R19.5 Other fecal abnormalities
R19.7 Diarrhea, unspecified
R19.8 Other specified symptoms and signs involving the digestive system and abdomen

CPT Codes

44388 Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed
44389 Colonoscopy through stoma; with biopsy, single or multiple
44390 Colonoscopy through stoma; with removal of foreign body
44391 Colonoscopy through stoma; with control of bleeding, any method
44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
44393 Colonoscopy through stoma; (with ablation of tumor(s), polyp(s), other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (code deleted 12/2014)
44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
44397 Colonoscopy through stoma; with transendoscopic stent placement (includes predilation) (code deleted 12/2014)
44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre and post dilation and guide wire passage, when performed)
44402 Colonoscopy through stoma; with endoscopic stent placement (including pre and post dilation and guide wire passage, when performed)
45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple (code deleted 12/2014)
45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed
45379 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, with removal of foreign body
45380 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed; with biopsy, single or multiple (code revised in 2015)
45381 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, with directed submucosal injection(s), any substance
45382 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, with control of bleeding, any method (code revised in 2015)
45383 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, with control of bleeding, with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal; by hot biopsy forceps, bipolar cautery or snare technique (code deleted 12/2014)
45384 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45386 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, with transendoscopic balloon dilation
45387 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, with transendoscopic stent placement (includes predilation) (code deleted 2015)
45388 Colonoscopy, flexible, with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre and post dilation and guide wire passage, when performed)
45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre and post dilation and guide wire passage) when performed
45399 Unlisted procedure, rectum

HCPCS Codes

G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G6019 Colonoscopy through stoma; with ablation of tumor(s), polyp(s) or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (code deleted 12/2015)
G6020 Colonoscopy through stoma; with transendoscopic stent placement (includes predilation) (code deleted 12/2015)
G6021 Unlisted procedure, intestine (code deleted 12/2015)
G6024 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s) or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar
cautery or snare technique (code deleted 12/2015)
G6025 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) (code deleted 12/2015)

Gastric Emptying Scintigraphy—CPT and ICD-9/ICD-10 Covered Indications

Claims submitted with non-covered indication will be denied as provider liable.


CPT Description

78264 Gastric emptying study (gastric emptying scintigraphy)
78265 Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel transit
78266 Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days

Related coding—Radiopharmaceutical diagnostic imaging agents that deny when gastric emptying scintigraphy is denied for a non covered indication:

A9541 Technetium tc-99m sulfur colloid, diagnostic, per study dose, up to20 mci’s
A4641 Radiopharmaceutical, diagnostic, not otherwise classified


ICD‐10 CM ‐  Diagnosis Code ICD‐10 CM ‐ Diagnosis Description

K21.9 Gastro‐esophageal reflux disease without esophagitis
K22.0 Achalasia of cardia
K30 Functional dyspepsia
K50.012 Crohn's disease of small intestine with intestinal obstruction
K50.112 Crohn's disease of large intestine with intestinal obstruction
K50.812 Crohn's disease of both small and large intestine with intestinal obstruction
K50.912 Crohn's disease, unspecified, with intestinal obstruction
K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction
K51.212 Ulcerative (chronic) proctitis with intestinal obstruction
K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction
K51.512 Left sided colitis with intestinal obstruction
K51.812 Other ulcerative colitis with intestinal obstruction
K51.912 Ulcerative colitis, unspecified with intestinal obstruction
K56.0 Paralytic ileus
K56.1 Intussusception
K56.2 Volvulus
K56.3 Gallstone ileus
K56.41 Fecal impaction
K56.49 Other impaction of intestine
K56.5 Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection)
K56.60 Unspecified intestinal obstruction
K56.69 Other intestinal obstruction
K56.7 Ileus, unspecified
K59.8 Other specified functional intestinal disorders
R11.0 Nausea
R11.10 Vomiting, unspecified
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.14 Bilious vomiting
R11.2 Nausea with vomiting, unspecified
R12 Heartburn
R13.0 Aphagia
R13.10 Dysphagia, unspecified
R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase
R13.13 Dysphagia, pharyngeal phase
R13.14 Dysphagia, pharyngoesophageal phase
R13.19 Other dysphagia
R14.0 Abdominal distension (gaseous)
R14.1 Gas pain
R14.2 Eructation
R14.3 Flatulence
R15.0 Incomplete defecation
R15.1 Fecal smearing
R15.2 Fecal urgency
R15.9 Full incontinence of feces
R19.11 Absent bowel sounds
R19.12 Hyperactive bowel sounds
R19.15 Other abnormal bowel sounds
R19.2 Visible peristalsis
R19.4 Change in bowel habit
R19.5 Other fecal abnormalities
R19.7 Diarrhea, unspecified

ICD -10 Codes

AØ9 Infectious gastroenteritis and colitis, unspecified
C17-C21.8 Malignant neoplasm of small intestine, colon, rectosigmoid junction, rectum, anus and anal canal
C76.3 Malignant neoplasm of pelvis
C77.2 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
D01.0-D01.49 Carcinoma in situ of colon, rectosigmoid junction, rectum, anal canal and anus and intestine
D12.Ø Benign neoplasm of cecum
D12.6 Benign neoplasm of colon, unspecified
D5Ø.Ø-D50.9 Iron deficiency anemia secondary to blood loss (chronic)
D62 Acute posthemorrhagic anemia
I33.Ø-I33.9 Acute and subacute infective endocarditis
K50-K50.919 Crohn’s disease
K51-K51.319 Ulcerative colitis
K51.4-K51.419 Inflammatory polyps of colon
K51.5-K519 Left sided colitis
K51.8-K51.919 Ulcerative colitis, unspecified
K52-K52.9 Other and unspecified noninfective gastroenteritis and colitis
K55-K55.9 Vascular disorders of intestine
K56-K56.7 Paralytic ileus
K57-K57.93 Diverticular disease of intestine
K58-K58.9 Irritable bowel syndrome
K59-K59.9 Other functional disorders
K62-K62.9 Other diseases of anus and rectum
K63-K63.9 Other diseases of intestine
K63.5 Polyp of colon
K91.8-K91.89 Other intraoperative and postprocedural complications and disorders of digestive system
K92-K92.9 Other diseases of digestive system
R19.4 Change in bowel habits
R19.5 Other fecal abnormalities
R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
T18.3XXA Foreign body in small intestine, initial encounter
T18.4XXA Foreign body in colon, initial encounter
Z12.I-Z12.3 Encounter for screening for malignant neoplasm of intestinal tract
Z12.11 Encounter for screening for malignant neoplasm of colon
Z8Ø.Ø Family history of malignant neoplasm of digestive organs
Z83.71 Family history of colonic polyps
Z85.00 Personal history of malignant neoplasm of unspecified digestive organ
Z86.Ø1Ø Personal history of colonic polyps
Z87.19 Personal history of other diseases of the digestive system
Z85.03-Z85.048 Personal history of malignant neoplasm of large intestine, rectum, rectosigmoid junction and anus
Z85.06-Z85.068 Personal history of malignant neoplasm of small intestine

Helicobacter Pylori Testing—CPT and ICD-9/ICD-10 Covered Indications


Claims submitted with non-covered indication will be denied as provider liable.


CPT Description

78267 Urea breath test, C-14 (isotopic); acquisition for analysis
78268 Urea breath test, C-14 (isotopic); analysis
83009 Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13)
83013 Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13)
83014 Helicobacter pylori; drug administration
86677 Antibody; helicobacter pylori
87338 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiplestep method; helicobacter pylori, stool
87339 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiplestep method; helicobacter pylori

Related coding—Upper gastrointestinal endoscopy with biopsy codes and not otherwise classified diagnostic radiopharmaceuticals that deny when helicobacter pylori (H. pylori) testing is denied for a non covered indication:

43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
A4641 Radiopharmaceutical, diagnostic, not otherwise classified


Code Description

B96.81 Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere
C16.0 Malignant neoplasm of cardia
C16.1 Malignant neoplasm of fundus of stomach
C16.2 Malignant neoplasm of body of stomach
C16.3 Malignant neoplasm of pyloric antrum
C16.4 Malignant neoplasm of pylorus
C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified
C16.6 Malignant neoplasm of greater curvature of stomach, unspecified
C16.8 Malignant neoplasm of overlapping sites of stomach
C16.9 Malignant neoplasm of stomach, unspecified
C82.50 Diffuse follicle center lymphoma, unspecified site
C82.59 Diffuse follicle center lymphoma, extranodal and solid organ sites
C83.80 Other non-follicular lymphoma, unspecified site
C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck
C83.82 Other non-follicular lymphoma, intrathoracic lymph nodes
C83.83 Other non-follicular lymphoma, intra-abdominal lymph nodes
C83.84 Other non-follicular lymphoma, lymph nodes of axilla and upper limb
C83.85 Other non-follicular lymphoma, lymph nodes of inguinal region and lower
C83.86 Other non-follicular lymphoma, intrapelvic lymph nodes
C83.87 Other non-follicular lymphoma, spleen
C83.88 Other non-follicular lymphoma, lymph nodes of multiple sites
C83.89 Other non-follicular lymphoma, extranodal and solid organ sites
C84.90 Mature T/NK-cell lymphomas, unspecified, unspecified site
C84.99 Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites
C84.A0 Cutaneous T-cell lymphoma, unspecified, unspecified site
C84.A9 Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites
C84.Z0 Other mature T/NK-cell lymphomas, unspecified site
C84.Z9 Other mature T/NK-cell lymphomas, extranodal and solid organ sites
C85.10 Unspecified B-cell lymphoma, unspecified site
C85.19 Unspecified B-cell lymphoma, extranodal and solid organ sites
C85.20 Mediastinal (thymic) large B-cell lymphoma, unspecified site
C85.29 Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites
C85.80 Other specified types of non-Hodgkin lymphoma, unspecified site
C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ
C85.90 Non-Hodgkin lymphoma, unspecified, unspecified site
C85.99 Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C86.4 Blastic NK-cell lymphoma
C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid
K25.0 Acute gastric ulcer with hemorrhage
K25.1 Acute gastric ulcer with perforation
K25.2 Acute gastric ulcer with both hemorrhage and perforation
K25.3 Acute gastric ulcer without hemorrhage or perforation
K25.4 Chronic or unspecified gastric ulcer with hemorrhage
K25.5 Chronic or unspecified gastric ulcer with perforation
K25.6 Chronic or unspecified gastric ulcer with both hemorrhage and perforation
K25.7 Chronic gastric ulcer without hemorrhage or perforation
K25.9 Gastric ulcer, unspecified as acute or chronic, without hemorrhage or
K26.0 Acute duodenal ulcer with hemorrhage
K26.1 Acute duodenal ulcer with perforation
K26.2 Acute duodenal ulcer with both hemorrhage and perforation
K26.3 Acute duodenal ulcer without hemorrhage or perforation
 Code Description
K26.4 Chronic or unspecified duodenal ulcer with hemorrhage
K26.5 Chronic or unspecified duodenal ulcer with perforation
K26.6 Chronic or unspecified duodenal ulcer with both hemorrhage and perforation
K26.7 Chronic duodenal ulcer without hemorrhage or perforation
K26.9 Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or
K27.0 Acute peptic ulcer, site unspecified, with hemorrhage
K27.1 Acute peptic ulcer, site unspecified, with perforation
K27.2 Acute peptic ulcer, site unspecified, with both hemorrhage and perforation
K27.3 Acute peptic ulcer, site unspecified, without hemorrhage or perforation
K27.4 Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage
K27.5 Chronic or unspecified peptic ulcer, site unspecified, with perforation
K27.6 Chronic or unspecified peptic ulcer, site unspecified, with both hemorrhage
K27.7 Chronic peptic ulcer, site unspecified, without hemorrhage or perforation
K27.9 Peptic ulcer, site unspecified, unspecified as acute or chronic, without
K28.0 Acute gastrojejunal ulcer with hemorrhage
K28.1 Acute gastrojejunal ulcer with perforation
K28.2 Acute gastrojejunal ulcer with both hemorrhage and perforation
K28.3 Acute gastrojejunal ulcer without hemorrhage or perforation
K28.4 Chronic or unspecified gastrojejunal ulcer with hemorrhage
K28.5 Chronic or unspecified gastrojejunal ulcer with perforation
K28.6 Chronic or unspecified gastrojejunal ulcer with both hemorrhage and
K28.7 Chronic gastrojejunal ulcer without hemorrhage or perforation
K28.9 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or
K29.00 Acute gastritis without bleeding
K29.01 Acute gastritis with bleeding
K29.30 Chronic superficial gastritis without bleeding
K29.31 Chronic superficial gastritis with bleeding
K29.40 Chronic atrophic gastritis without bleeding
K29.41 Chronic atrophic gastritis with bleeding
K29.50 Unspecified chronic gastritis without bleeding
K29.51 Unspecified chronic gastritis with bleeding
K29.60 Other gastritis without bleeding
K29.61 Other gastritis with bleeding
K29.70 Gastritis, unspecified, without bleeding
K29.71 Gastritis, unspecified, with bleeding
K29.80 Duodenitis without bleeding
K29.81 Duodenitis with bleeding
K29.90 Gastroduodenitis, unspecified, without bleeding
K29.91 Gastroduodenitis, unspecified, with bleeding
K30 Functional dyspepsia
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.84 Generalized abdominal pain
Z87.11 Personal history of peptic ulcer disease

Tufts Health Plan sets frequency limits on certain procedures based on medical necessity. The following are policies that fall within frequency limitations.


Colorectal Screening

In accordance with CMS4, Tufts Health Plan will not compensate for:

** Fecal occult blood tests (82270, 82274) more than once every 12 months for patients over the age of 50.
** A sigmoidoscopy or barium enema more than once within 48 months.
** A colonoscopy or a barium enema on individuals at high risk more than once within 23 months.
** A diagnostic, non-high risk colonoscopy more than once within a 10-year period unless a colorectal cancer screening; sigmoidoscopy has been billed in the previous 4 years.

Effective for dates of service on or after October 1, 2015, Tufts Health Plan will limit coverage of colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 AND BMP3) to one visit within three (3) years, consistent with clinical guidelines


Mutually Exclusive

National Correct Coding Initiative (CCI) has identified procedures that are considered mutually exclusive. Mutually exclusive procedures are those procedures that cannot be reasonably performed in the same operative session. When the same provider bills mutually exclusive procedures for the same date of service, then the procedure with the lowest allowed amount is compensated.

The AMA created modifier 33 to allow providers to identify a preventive service for which, under the PPACA, there is no patient cost sharing. Use modifier 33 with a CPT code for a diagnostic/treatment service performed as a preventive service, such as a screening colonoscopy, even if a polyp is found and removed.

You may also use G codes intended for use for screening procedures for colorectal cancer screening:

o G0105: colonoscopy screening for individuals at high risk
o G0121: colonoscopy screening for individuals who are not high risk
o G0104: flexible sigmoidoscopy screening

When billing for preventive screening colonoscopy or sigmoidoscopy for any BCBSMA member, use modifier 33 or one of the G codes above so that the claim pays without any member cost share, according to the member’s benefits.

Do not use modifier 33 to bill for individuals receiving procedures due to signs or symptoms, or to rule out or confirm a suspected diagnosis. In this case, the procedure would be considered a diagnostic exam, not a screening exam. See the table on page 1 for coding examples. As always, be sure to check eligibility and benefits to determine appropriate member cost-sharing

National Guidelines
National guidelines recommend colorectal cancer screening starting at age 50 then every 10
years. However, more frequent or earlier screening is recommended for patients with certain
increased risk factors, such as a family history of colon cancer or personal history of polyps.
Screening in these situations will now also be covered when billed as a preventive service.**

Code Description Comments

43647–43648 Laparoscopy, surgical: gastric neurostimulator procedures

43881-43882 Gastric neurostimulator, procedures open

95980–95982 Electronic analysis of implanted neurostimulator pulse generator system

Will only be reimbursed when billed with the following diagnosis codes:

Code Description

'K31.84' Gastroparesis



43257 (Stretta procedure) Upper gastrointestinal endoscopy including esophagus, stomach, and either duodenum and/or jejunum; diagnostic, w/delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of GERD    Not reimbursed


74261,74262 CT colonography, diagnostic, including image postprocessing; with and without contrast
Prior authorization is required

Important Changes for Submitting Routine/Screening Colonoscopy Claims

We want to make you aware of recent changes that impact submitting claims for routine/screening colonoscopy services performed at an ambulatory surgical center.

51-Modifier
Effective April 16, 2016, you no longer need to include a 51-modifier for routine/screening colonoscopy claims if the service is performed at an ambulatory surgical center (ASC). This change ensures that routine/screening colonoscopy claims with one or more additional procedures will process according to multiple surgery guidelines.


We encourage ASCs to update their billing systems accordingly as Florida Blue no longer requires a modifier in order to apply appropriate reductions for secondary surgical procedures. ASCs should continue to place appropriate National Correct Coding Initiative and Medically Unlikely Edit modifiers in the first modifier position on the claim form.


Additional Diagnosis Code Fields

We also expanded the number of diagnosis code fields used to identify screening colonoscopy services. Claims now process according to colonoscopy screening benefits, as long as the benefit limit is not met, and there is a screening diagnosis code in position one, two, or three of the claim.

Important Tips

• A 51-modifier is no longer required for routine/screening colonoscopy claims that include one or more additional surgical procedures. A screening diagnosis code in position one, two, or three identifies the colonoscopy procedure as a screening service. If the benefit limit is not met,
routine benefits will apply.

• Be sure to place any payment modifiers, especially those for National Correct Coding Initiative and Medically Unlikely Edits, in the first modifier position as Florida Blue has not yet enhanced our claim processing system to accept up to four modifiers.

• You do not need to resubmit impacted routine/screening colonoscopy claims that processed incorrectly for multiple surgery guidelines. We will automatically reprocess these claims for you. • If a claim did not process correctly because a payment modifier was placed in a modifier

position other than the first position, please call the Provider Contact Center at (800) 727-2227 to let us know. We can change the modifier position and reprocess the claim.

If you have questions, please contact your network manager or provider solutions advisor

CPT Description

78267 Urea breath test, C-14 (isotopic); acquisition for analysis
78268 Urea breath test, C-14 (isotopic); analysis
83009 Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13)
83013 Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13)
83014 Helicobacter pylori; drug administration
86677 Antibody; helicobacter pylori
87338 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiplestep method; helicobacter pylori, stool
87339 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiplestep method; helicobacter pylori

Related coding—Upper gastrointestinal endoscopy with biopsy codes and not otherwise classified diagnostic radiopharmaceuticals that deny when helicobacter pylori (H. pylori) testing is denied for a non covered indication:

43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
A4641 Radiopharmaceutical, diagnostic, not otherwise classified

Code Description
B96.81 Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere
C16.0 Malignant neoplasm of cardia
C16.1 Malignant neoplasm of fundus of stomach
C16.2 Malignant neoplasm of body of stomach
C16.3 Malignant neoplasm of pyloric antrum
C16.4 Malignant neoplasm of pylorus
C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified
C16.6 Malignant neoplasm of greater curvature of stomach, unspecified
C16.8 Malignant neoplasm of overlapping sites of stomach
C16.9 Malignant neoplasm of stomach, unspecified
C82.50 Diffuse follicle center lymphoma, unspecified site
C82.59 Diffuse follicle center lymphoma, extranodal and solid organ sites
C83.80 Other non-follicular lymphoma, unspecified site
C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck
C83.82 Other non-follicular lymphoma, intrathoracic lymph nodes
C83.83 Other non-follicular lymphoma, intra-abdominal lymph nodes
C83.84 Other non-follicular lymphoma, lymph nodes of axilla and upper limb
C83.85 Other non-follicular lymphoma, lymph nodes of inguinal region and lower
C83.86 Other non-follicular lymphoma, intrapelvic lymph nodes
C83.87 Other non-follicular lymphoma, spleen
C83.88 Other non-follicular lymphoma, lymph nodes of multiple sites
C83.89 Other non-follicular lymphoma, extranodal and solid organ sites
C84.90 Mature T/NK-cell lymphomas, unspecified, unspecified site
C84.99 Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites
C84.A0 Cutaneous T-cell lymphoma, unspecified, unspecified site
C84.A9 Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites
C84.Z0 Other mature T/NK-cell lymphomas, unspecified site
C84.Z9 Other mature T/NK-cell lymphomas, extranodal and solid organ sites
C85.10 Unspecified B-cell lymphoma, unspecified site
C85.19 Unspecified B-cell lymphoma, extranodal and solid organ sites
C85.20 Mediastinal (thymic) large B-cell lymphoma, unspecified site
C85.29 Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites
C85.80 Other specified types of non-Hodgkin lymphoma, unspecified site
C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ
C85.90 Non-Hodgkin lymphoma, unspecified, unspecified site
C85.99 Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C86.4 Blastic NK-cell lymphoma
C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid
K25.0 Acute gastric ulcer with hemorrhage
K25.1 Acute gastric ulcer with perforation
K25.2 Acute gastric ulcer with both hemorrhage and perforation
K25.3 Acute gastric ulcer without hemorrhage or perforation
K25.4 Chronic or unspecified gastric ulcer with hemorrhage
K25.5 Chronic or unspecified gastric ulcer with perforation
K25.6 Chronic or unspecified gastric ulcer with both hemorrhage and perforation
K25.7 Chronic gastric ulcer without hemorrhage or perforation
K25.9 Gastric ulcer, unspecified as acute or chronic, without hemorrhage or
K26.0 Acute duodenal ulcer with hemorrhage
K26.1 Acute duodenal ulcer with perforation
K26.2 Acute duodenal ulcer with both hemorrhage and perforation
K26.3 Acute duodenal ulcer without hemorrhage or perforation


 Code Description
K26.4 Chronic or unspecified duodenal ulcer with hemorrhage
K26.5 Chronic or unspecified duodenal ulcer with perforation
K26.6 Chronic or unspecified duodenal ulcer with both hemorrhage and perforation
K26.7 Chronic duodenal ulcer without hemorrhage or perforation
K26.9 Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or
K27.0 Acute peptic ulcer, site unspecified, with hemorrhage
K27.1 Acute peptic ulcer, site unspecified, with perforation
K27.2 Acute peptic ulcer, site unspecified, with both hemorrhage and perforation
K27.3 Acute peptic ulcer, site unspecified, without hemorrhage or perforation
K27.4 Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage
K27.5 Chronic or unspecified peptic ulcer, site unspecified, with perforation
K27.6 Chronic or unspecified peptic ulcer, site unspecified, with both hemorrhage
K27.7 Chronic peptic ulcer, site unspecified, without hemorrhage or perforation
K27.9 Peptic ulcer, site unspecified, unspecified as acute or chronic, without
K28.0 Acute gastrojejunal ulcer with hemorrhage
K28.1 Acute gastrojejunal ulcer with perforation
K28.2 Acute gastrojejunal ulcer with both hemorrhage and perforation
K28.3 Acute gastrojejunal ulcer without hemorrhage or perforation
K28.4 Chronic or unspecified gastrojejunal ulcer with hemorrhage
K28.5 Chronic or unspecified gastrojejunal ulcer with perforation
K28.6 Chronic or unspecified gastrojejunal ulcer with both hemorrhage and
K28.7 Chronic gastrojejunal ulcer without hemorrhage or perforation
K28.9 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or
K29.00 Acute gastritis without bleeding
K29.01 Acute gastritis with bleeding
K29.30 Chronic superficial gastritis without bleeding
K29.31 Chronic superficial gastritis with bleeding
K29.40 Chronic atrophic gastritis without bleeding
K29.41 Chronic atrophic gastritis with bleeding
K29.50 Unspecified chronic gastritis without bleeding
K29.51 Unspecified chronic gastritis with bleeding
K29.60 Other gastritis without bleeding
K29.61 Other gastritis with bleeding
K29.70 Gastritis, unspecified, without bleeding
K29.71 Gastritis, unspecified, with bleeding
K29.80 Duodenitis without bleeding
K29.81 Duodenitis with bleeding
K29.90 Gastroduodenitis, unspecified, without bleeding
K29.91 Gastroduodenitis, unspecified, with bleeding
K30 Functional dyspepsia
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.84 Generalized abdominal pain
Z87.11 Personal history of peptic ulcer disease

Code Description Comments

31525, 31575 Diagnostic laryngoscopy
43215 Esophagoscopy for removal of foreign body
43220 Esophageal endoscopy dilation
43257 (Stretta procedure) Upper gastrointestinal endoscopy including esophagus, stomach, and either duodenum and/or jejunum; diagnostic, w/delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of GERD Not reimbursed
43312 Esophagoplasty, (plastic repair or reconstruction) thoracic
43621 Gastrectomy, total; with Roux-en-Y reconstruction
43633 Gastrectomy, partial, distal with Roux-en-Y reconstruction
43644 Laparoscopy, surgical, gastric restrictive procedure; w/gastric bypass
and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645 Laparoscopy, surgical, gastric restrictive procedure; w/gastric
bypass and small intestine reconstruction to limit absorption
43647–43648 Laparoscopy, surgical: gastric neurostimulator procedures Will only be reimbursed when billed with the following diagnosis codes:
43770–43774 Laparoscopic, gastric restrictive procedures
43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie; sleeve gastrectomy) Procedure is reimbursed when medically
necessary with prior authorization
43830 Gastrostomy, without construction of gastric tube Not reimbursed when billed with any major abdominal procedure
43842 Gastric restrictive procedure, w/o gastric bypass, vertical-banded gastroplasty Not reimbursed as of 3/24/16
43843 Gastric restrictive procedure, w/o gastric bypass, other than vertical- banded gastroplasty 43845 Gastric restrictive procedure w/ partial gastrectomy, pylorusreserving duodenoileostomy and ileoileostomy to limit absorption (biliopancreatic diversion with duodenal switch)
43846 Gastric restrictive procedure, w/gastric bypass; Roux-en-Y  gastroenterostomy
43881-43882 Gastric neurostimulator, procedures open Will only be reimbursed when billed with the following diagnosis codes:
ICD-9 Covered Indications 536.3 ICD-10 Covered Indications
43886–43888 Gastric restrictive procedures
45317 Proctosigmoidoscopy with control of bleeding
74261,74262 CT colonography, diagnostic, including image postprocessing; with and without contrast Prior authorization is required
74263 Screening virtual colonoscopy Not reimbursed
91110 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with physician interpretation and report Will only be reimbursed when billed with the following diagnosis codes:
ICD-9 Covered Indications
209.00–209.03, 209.40–209.43, 211.2, 280.0, 280.1, 280.8, 280.9, 555.0, 555.1, 555.2, 555.9, 578.0, 578.1, 578.9, 579.0, 759.6 ICD-10 Covered Indications
91111 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus, with physician interpretation and report Not reimbursed
91112 Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule with interpretation and report Not reimbursed as of 3/1/16
91132, 91133 Electrogastrography, diagnostic, transcutaneous; with or without provocative testing Not reimbursed
91299 Unlisted diagnostic gastroenterology procedure Not reimbursed when billed for SmartPill GI Monitoring System
95980–95982 Electronic analysis of implanted neurostimulator pulse generator system ICD-9 Covered Indications 536.3 ICD-10 Covered Indications
99026, 99027 Hospital-mandated physician on-call services
Not reimbursed
99143–99145 Moderate sedation services

Diagnostic and Therapeutic Esophagogastroduodenoscopy

CPT/HCPCS Codes

43233Egd balloon dil esoph30 mm/>
43235Egd diagnostic brush wash
43236Uppr gi scope w/submuc inj
43237Endoscopic us exam esoph
43238Egd us fine needle bx/aspir
43239Egd biopsy single/multiple
43241Egd tube/cath insertion
43243Egd injection varices
43244Egd varices ligation
43245Egd dilate stricture
43246Egd place gastrostomy tube
43247Egd remove foreign body
43248Egd guide wire insertion
43249Esoph egd dilation <30 mm="" p="">43250Egd cautery tumor polyp
43251Egd remove lesion snare
43253Egd us transmural injxn/mark
43254Egd endo mucosal resection
43255Egd control bleeding any
43266Egd endoscopic stent place
43270Egd lesion ablation


Coverage Indications, Limitations, and/or Medical Necessity

Upper intestinal endoscopy is performed with a lighted, flexible, fiberoptic instrument passed through the cricopharynx. The patient receives conscious sedation. A topical anesthetic is sometimes applied to the posterior pharynx. Direct visualization of the entire esophagus, stomach, and duodenum (to the junction of the second and third portions) can be accomplished easily with modern instruments that are less than 12mm in diameter. Esophagogastroduodenoscopy (EGD) is a technique utilized to examine, obtain samples, and in some instances, to treat pathological conditions.

Diagnostic observations are made concerning focal benign or malignant lesions, diffuse mucosal changes, luminal obstruction, motility, and extrinsic compression by contiguous structures. A diagnostic EGD allows the examiner to visualize abnormalities detectable by the technique and to photograph, biopsy, and/or remove lesions as appropriate.

The purpose of the therapeutic EGD is to manage hemorrhage; remove foreign bodies and neoplastic growths; to relieve obstruction due to stricture, malignancy, or other causes through dilatation or the placement of stents; and to assist in the placement of percutaneous gastrostomy tubes.

EGD(s)will be considered medically reasonable and necessary under the following diagnostic conditions:

· Patient has upper abdominal distress (e.g., gastroesophageal reflux disease) which persists despite an appropriate trial of symptomatic therapy;

· Patient has upper abdominal distress associated with a short history of signs and symptoms suggesting significant associated disease or illness (e.g., weight loss, anorexia, vomiting, nonsteroidal anti-inflammatory drug [NSAID] intake, other gastric irritant intake);

· Patients over the age of 40 who have experienced a significant history of heartburn that returns after a course of symptomatic therapy;

· Patients who have dysphagia or odynophagia;

· Patient has persistent, unexplained vomiting;

· Patient has upper gastrointestinal x-ray findings of:

any lesion that requires biopsy for diagnosis; or-

gastric ulcer suspicious of cancer; or

evidence of stricture or obstruction;

· To assess acute injury after caustic agent ingestion;

· When anti-reflux surgery is contemplated; or

· Patient has gastrointestinal bleeding:

in most actively bleeding patients; or

for presumed chronic blood loss and iron deficiency anemia when investigation of large bowel is negative.

EGD(s) will be considered medically reasonable and necessary for the following therapeutic purposes:
Treatment of bleeding lesions;

Removal of foreign bodies;

Sclerotherapy and/or band ligation for bleeding from esophageal or gastric varices;

Dilatation of strictures in the upper intestinal tract;

Removal of selected polypoid lesions;

Placement of feeding tubes; or

Palliative therapy of stenosing neoplasms (e.g., laser, stent placement).
,
Gastrointestinal bleeding may be treated with a variety of methods. Direct contact heater probes and hemostatic injections into or around the bleeding vessels are both effective therapy for acute bleeding.

Foreign body removal from the stomach or esophagus is usually successful with these flexible instruments. The foreign bodies can be retrieved by either of two methods. The first method is to capture the foreign body with a snare device/grasping forceps and pull the item out with the endoscope. The second method is accomplished by piecemeal destruction and pushing the bolus through the esophagus into the stomach.

Esophageal varices may be injected with a variety of sclerosing solutions. Eradication of varices requires, on the average, five sclerotherapy sessions, with multiple injections given during each session.

Dilatation of strictures may be accomplished with a balloon placed through the endoscope and inflated using hydrostatic pressure. Bougies are rubber dilators available in various sizes up to approximately 2.0cm. Plastic bougies and other dilating probes are usually passed over a guide wire. This procedure involves placing the guide wire into the stomach through the endoscope. The endoscope is then withdrawn leaving the guide wire in place. The dilating probes and plastic bougies are then passed over the guide wire. After the largest dilator is used, the dilator and guide wire are removed. Esophageal dilation is performed after a definitive diagnosis has been established in patients exhibiting dysphagia. The goal in most cases is a lumenal diameter of 16-17mm which allows passage of solid food. A series of dilators may be passed over the guide wire to reach the goal of therapy.

Follow-up EGD(s)will be considered medically reasonable and necessary for the following indications:

Biopsy surveillance of patients with Barrett’s esophagus every 12 to 24 months. However, if dysplasia is present, earlier surveillance intervals of from three to six months may be required;

Follow-up of gastric ulcers to healing or satisfaction that they are benign;

Follow-up and treatment of esophageal strictures requiring guidewire dilation;

Follow-up of duodenal ulcer or other lesions of the upper gastrointestinal tract that have resulted in serious consequences (e.g., hemorrhage);

Follow-up of patients having a previous gastric polypectomy for adenoma; or

Follow-up and treatment of patients with esophageal varices or bleeding lesions requiring recurrent therapy (e.g., esophageal varices, gastric varices, angiodysplastic or watermelon stomach lesions, radiation gastritis).

Follow-up for removal of percutaneous gastrostomy tube (PEG)

Periodic EGD is NOT usually indicated in the following situations:
Surveillance of healed, benign disease such as gastric or duodenal ulcer or benign esophageal strictures; or

Cancer surveillance in patients with pernicious anemia, treated achalasia, or prior gastric resection.


EGD is generally contraindicated for patients with recent myocardial infarction.


Revenue Codes
CodeDescription

0360Operating Room Services - General Classification
0361Operating Room Services - Minor Surgery
0750Gastro-Intestinal (GI) Services - General Classification30>

ICD-10 Codes that Support Medical Necessity

B25.2Cytomegaloviral pancreatitis
B37.81Candidal esophagitis
C15.3Malignant neoplasm of upper third of esophagus
C15.4Malignant neoplasm of middle third of esophagus
C15.5Malignant neoplasm of lower third of esophagus
C15.8Malignant neoplasm of overlapping sites of esophagus
C15.9Malignant neoplasm of esophagus, unspecified
C16.0Malignant neoplasm of cardia
C16.1Malignant neoplasm of fundus of stomach
C16.2Malignant neoplasm of body of stomach
C16.3Malignant neoplasm of pyloric antrum
C16.4Malignant neoplasm of pylorus
C16.5Malignant neoplasm of lesser curvature of stomach, unspecified
C16.6Malignant neoplasm of greater curvature of stomach, unspecified
C16.8Malignant neoplasm of overlapping sites of stomach
C16.9Malignant neoplasm of stomach, unspecified
C17.0Malignant neoplasm of duodenum
C17.1Malignant neoplasm of jejunum
C17.2Malignant neoplasm of ileum
C17.3Meckel's diverticulum, malignant
C17.8Malignant neoplasm of overlapping sites of small intestine
C17.9Malignant neoplasm of small intestine, unspecified
C22.0Liver cell carcinoma
C22.2Hepatoblastoma
C22.3Angiosarcoma of liver
C22.4Other sarcomas of liver
C22.7Other specified carcinomas of liver
C22.8Malignant neoplasm of liver, primary, unspecified as to type
C23Malignant neoplasm of gallbladder
C24.0Malignant neoplasm of extrahepatic bile duct
C24.1Malignant neoplasm of ampulla of Vater
C24.8Malignant neoplasm of overlapping sites of biliary tract
C24.9Malignant neoplasm of biliary tract, unspecified
C25.0Malignant neoplasm of head of pancreas
C25.1Malignant neoplasm of body of pancreas
C25.2Malignant neoplasm of tail of pancreas
C25.3Malignant neoplasm of pancreatic duct
C25.4Malignant neoplasm of endocrine pancreas
C25.7Malignant neoplasm of other parts of pancreas
C25.8Malignant neoplasm of overlapping sites of pancreas
C25.9Malignant neoplasm of pancreas, unspecified
C26.9Malignant neoplasm of ill-defined sites within the digestive system
C46.4Kaposi's sarcoma of gastrointestinal sites
C78.4Secondary malignant neoplasm of small intestine
C78.6Secondary malignant neoplasm of retroperitoneum and peritoneum
C79.89Secondary malignant neoplasm of other specified sites
C79.9Secondary malignant neoplasm of unspecified site
C82.50Diffuse follicle center lymphoma, unspecified site
C82.59Diffuse follicle center lymphoma, extranodal and solid organ sites
C84.90Mature T/NK-cell lymphomas, unspecified, unspecified site
C84.99Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites
C84.A0Cutaneous T-cell lymphoma, unspecified, unspecified site
C84.A9Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites
C84.Z0Other mature T/NK-cell lymphomas, unspecified site
C84.Z9Other mature T/NK-cell lymphomas, extranodal and solid organ sites
C85.10Unspecified B-cell lymphoma, unspecified site
C85.19Unspecified B-cell lymphoma, extranodal and solid organ sites
C85.20Mediastinal (thymic) large B-cell lymphoma, unspecified site
C85.29Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites
C85.80Other specified types of non-Hodgkin lymphoma, unspecified site
C85.89Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites
C85.90Non-Hodgkin lymphoma, unspecified, unspecified site
C85.99Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C86.4Blastic NK-cell lymphoma
D00.1Carcinoma in situ of esophagus
D00.2Carcinoma in situ of stomach
D01.0Carcinoma in situ of colon
D01.1Carcinoma in situ of rectosigmoid junction
D01.2Carcinoma in situ of rectum
D01.3Carcinoma in situ of anus and anal canal
D01.40Carcinoma in situ of unspecified part of intestine
D01.49Carcinoma in situ of other parts of intestine
D01.5Carcinoma in situ of liver, gallbladder and bile ducts
D12.0Benign neoplasm of cecum
D12.1Benign neoplasm of appendix
D12.2Benign neoplasm of ascending colon
D12.3Benign neoplasm of transverse colon
D12.4Benign neoplasm of descending colon
D12.5Benign neoplasm of sigmoid colon
D12.6Benign neoplasm of colon, unspecified
D12.7Benign neoplasm of rectosigmoid junction
D12.8Benign neoplasm of rectum
D12.9Benign neoplasm of anus and anal canal
D13.0Benign neoplasm of esophagus
D13.1Benign neoplasm of stomach
D13.2Benign neoplasm of duodenum
D13.30Benign neoplasm of unspecified part of small intestine
D13.39Benign neoplasm of other parts of small intestine
D13.4Benign neoplasm of liver
D13.5Benign neoplasm of extrahepatic bile ducts
D13.6Benign neoplasm of pancreas
D13.7Benign neoplasm of endocrine pancreas
D13.9Benign neoplasm of ill-defined sites within the digestive system
D17.5Benign lipomatous neoplasm of intra-abdominal organs
D17.71Benign lipomatous neoplasm of kidney
D17.9Benign lipomatous neoplasm, unspecified
D18.03Hemangioma of intra-abdominal structures
D19.1Benign neoplasm of mesothelial tissue of peritoneum
D20.0Benign neoplasm of soft tissue of retroperitoneum
D20.1Benign neoplasm of soft tissue of peritoneum
D37.1Neoplasm of uncertain behavior of stomach
D37.2Neoplasm of uncertain behavior of small intestine
D37.3Neoplasm of uncertain behavior of appendix
D37.4Neoplasm of uncertain behavior of colon
D37.5Neoplasm of uncertain behavior of rectum
D37.6Neoplasm of uncertain behavior of liver, gallbladder and bile ducts
D48.3Neoplasm of uncertain behavior of retroperitoneum
D48.4Neoplasm of uncertain behavior of peritoneum
D49.0Neoplasm of unspecified behavior of digestive system
D50.0Iron deficiency anemia secondary to blood loss (chronic)
D50.1Sideropenic dysphagia
D50.8Other iron deficiency anemias
D50.9Iron deficiency anemia, unspecified
D62Acute posthemorrhagic anemia
E16.4Increased secretion of gastrin
E16.9Disorder of pancreatic internal secretion, unspecified
E41Nutritional marasmus
E44.0Moderate protein-calorie malnutrition
E44.1Mild protein-calorie malnutrition
E45Retarded development following protein-calorie malnutrition
E46Unspecified protein-calorie malnutrition
E64.0Sequelae of protein-calorie malnutrition
F44.4Conversion disorder with motor symptom or deficit
F44.5Conversion disorder with seizures or convulsions
F44.6Conversion disorder with sensory symptom or deficit
F44.7Conversion disorder with mixed symptom presentation
F45.8Other somatoform disorders
F50.00Anorexia nervosa, unspecified
F50.01Anorexia nervosa, restricting type
F50.02Anorexia nervosa, binge eating/purging type
F50.2Bulimia nervosa
F50.8Other eating disorders
F50.9Eating disorder, unspecified
F98.21Rumination disorder of infancy
F98.3Pica of infancy and childhood
I69.091Dysphagia following nontraumatic subarachnoid hemorrhage
I69.191Dysphagia following nontraumatic intracerebral hemorrhage
I69.291Dysphagia following other nontraumatic intracranial hemorrhage
I69.391Dysphagia following cerebral infarction
I69.891Dysphagia following other cerebrovascular disease
I69.991Dysphagia following unspecified cerebrovascular disease
I77.2Rupture of artery
I78.0Hereditary hemorrhagic telangiectasia
I85.00Esophageal varices without bleeding
I85.01Esophageal varices with bleeding
I85.10Secondary esophageal varices without bleeding
I85.11Secondary esophageal varices with bleeding
J69.0Pneumonitis due to inhalation of food and vomit
J86.0Pyothorax with fistula
K20.0Eosinophilic esophagitis
K20.8Other esophagitis
K20.9Esophagitis, unspecified
K21.0Gastro-esophageal reflux disease with esophagitis
K21.9Gastro-esophageal reflux disease without esophagitis
K22.0Achalasia of cardia
K22.10Ulcer of esophagus without bleeding
K22.11Ulcer of esophagus with bleeding
K22.2Esophageal obstruction
K22.3Perforation of esophagus
K22.4Dyskinesia of esophagus
K22.5Diverticulum of esophagus, acquired
K22.6Gastro-esophageal laceration-hemorrhage syndrome
K22.70Barrett's esophagus without dysplasia
K22.710Barrett's esophagus with low grade dysplasia
K22.711Barrett's esophagus with high grade dysplasia
K22.719Barrett's esophagus with dysplasia, unspecified
K22.8Other specified diseases of esophagus
K23Disorders of esophagus in diseases classified elsewhere
K25.0Acute gastric ulcer with hemorrhage
K25.1Acute gastric ulcer with perforation
K25.2Acute gastric ulcer with both hemorrhage and perforation
K25.3Acute gastric ulcer without hemorrhage or perforation
K25.4Chronic or unspecified gastric ulcer with hemorrhage
K25.5Chronic or unspecified gastric ulcer with perforation
K25.6Chronic or unspecified gastric ulcer with both hemorrhage and perforation
K25.7Chronic gastric ulcer without hemorrhage or perforation
K25.9Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation
K26.0Acute duodenal ulcer with hemorrhage
K26.1Acute duodenal ulcer with perforation
K26.2Acute duodenal ulcer with both hemorrhage and perforation
K26.3Acute duodenal ulcer without hemorrhage or perforation
K26.4Chronic or unspecified duodenal ulcer with hemorrhage
K26.5Chronic or unspecified duodenal ulcer with perforation
K26.6Chronic or unspecified duodenal ulcer with both hemorrhage and perforation
K26.7Chronic duodenal ulcer without hemorrhage or perforation
K26.9Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
K27.0Acute peptic ulcer, site unspecified, with hemorrhage
K27.1Acute peptic ulcer, site unspecified, with perforation
K27.2Acute peptic ulcer, site unspecified, with both hemorrhage and perforation
K27.3Acute peptic ulcer, site unspecified, without hemorrhage or perforation
K27.4Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage
K27.5Chronic or unspecified peptic ulcer, site unspecified, with perforation
K27.6Chronic or unspecified peptic ulcer, site unspecified, with both hemorrhage and perforation
K27.7Chronic peptic ulcer, site unspecified, without hemorrhage or perforation
K27.9Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation
K28.0Acute gastrojejunal ulcer with hemorrhage
K28.1Acute gastrojejunal ulcer with perforation
K28.2Acute gastrojejunal ulcer with both hemorrhage and perforation
K28.3Acute gastrojejunal ulcer without hemorrhage or perforation
K28.4Chronic or unspecified gastrojejunal ulcer with hemorrhage
K28.5Chronic or unspecified gastrojejunal ulcer with perforation
K28.6Chronic or unspecified gastrojejunal ulcer with both hemorrhage and perforation
K28.7Chronic gastrojejunal ulcer without hemorrhage or perforation
K28.9Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
K29.00Acute gastritis without bleeding
K29.01Acute gastritis with bleeding
K29.20Alcoholic gastritis without bleeding
K29.21Alcoholic gastritis with bleeding
K29.30Chronic superficial gastritis without bleeding
K29.31Chronic superficial gastritis with bleeding
K29.40Chronic atrophic gastritis without bleeding
K29.41Chronic atrophic gastritis with bleeding
K29.50Unspecified chronic gastritis without bleeding
K29.51Unspecified chronic gastritis with bleeding
K29.60Other gastritis without bleeding
K29.61Other gastritis with bleeding
K29.70Gastritis, unspecified, without bleeding
K29.71Gastritis, unspecified, with bleeding
K29.80Duodenitis without bleeding
K29.81Duodenitis with bleeding
K29.90Gastroduodenitis, unspecified, without bleeding
K29.91Gastroduodenitis, unspecified, with bleeding
K30Functional dyspepsia
K31.0Acute dilatation of stomach
K31.1Adult hypertrophic pyloric stenosis
K31.2Hourglass stricture and stenosis of stomach
K31.3Pylorospasm, not elsewhere classified
K31.4Gastric diverticulum
K31.5Obstruction of duodenum
K31.6Fistula of stomach and duodenum
K31.7Polyp of stomach and duodenum
K31.811Angiodysplasia of stomach and duodenum with bleeding
K31.819Angiodysplasia of stomach and duodenum without bleeding
K31.82Dieulafoy lesion (hemorrhagic) of stomach and duodenum
K31.84Gastroparesis
K31.89Other diseases of stomach and duodenum
K44.0Diaphragmatic hernia with obstruction, without gangrene
K44.1Diaphragmatic hernia with gangrene
K44.9Diaphragmatic hernia without obstruction or gangrene
K45.0Other specified abdominal hernia with obstruction, without gangrene
K50.00Crohn's disease of small intestine without complications
K50.011Crohn's disease of small intestine with rectal bleeding
K50.012Crohn's disease of small intestine with intestinal obstruction
K50.013Crohn's disease of small intestine with fistula
K50.014Crohn's disease of small intestine with abscess
K50.018Crohn's disease of small intestine with other complication
K50.019Crohn's disease of small intestine with unspecified complications
K50.10Crohn's disease of large intestine without complications
K50.111Crohn's disease of large intestine with rectal bleeding
K50.112Crohn's disease of large intestine with intestinal obstruction
K50.113Crohn's disease of large intestine with fistula
K50.114Crohn's disease of large intestine with abscess
K50.118Crohn's disease of large intestine with other complication
K50.119Crohn's disease of large intestine with unspecified complications
K50.80Crohn's disease of both small and large intestine without complications
K50.811Crohn's disease of both small and large intestine with rectal bleeding
K50.812Crohn's disease of both small and large intestine with intestinal obstruction
K50.813Crohn's disease of both small and large intestine with fistula
K50.814Crohn's disease of both small and large intestine with abscess
K50.818Crohn's disease of both small and large intestine with other complication
K50.819Crohn's disease of both small and large intestine with unspecified complications
K50.90Crohn's disease, unspecified, without complications
K50.911Crohn's disease, unspecified, with rectal bleeding
K50.912Crohn's disease, unspecified, with intestinal obstruction
K50.913Crohn's disease, unspecified, with fistula
K50.914Crohn's disease, unspecified, with abscess
K50.918Crohn's disease, unspecified, with other complication
K50.919Crohn's disease, unspecified, with unspecified complications
K52.2Allergic and dietetic gastroenteritis and colitis
K52.81Eosinophilic gastritis or gastroenteritis
K52.89Other specified noninfective gastroenteritis and colitis
K56.60Unspecified intestinal obstruction
K57.00Diverticulitis of small intestine with perforation and abscess without bleeding
K57.01Diverticulitis of small intestine with perforation and abscess with bleeding
K57.11Diverticulosis of small intestine without perforation or abscess with bleeding
K57.12Diverticulitis of small intestine without perforation or abscess without bleeding
K57.13Diverticulitis of small intestine without perforation or abscess with bleeding
K57.40Diverticulitis of both small and large intestine with perforation and abscess without bleeding
K57.41Diverticulitis of both small and large intestine with perforation and abscess with bleeding
K57.51Diverticulosis of both small and large intestine without perforation or abscess with bleeding
K57.52Diverticulitis of both small and large intestine without perforation or abscess without bleeding
K57.53Diverticulitis of both small and large intestine without perforation or abscess with bleeding
K63.3Ulcer of intestine
K63.5Polyp of colon
K70.10Alcoholic hepatitis without ascites
K70.11Alcoholic hepatitis with ascites
K70.2Alcoholic fibrosis and sclerosis of liver
K70.30Alcoholic cirrhosis of liver without ascites
K70.31Alcoholic cirrhosis of liver with ascites
K70.40Alcoholic hepatic failure without coma
K70.41Alcoholic hepatic failure with coma
K70.9Alcoholic liver disease, unspecified
K73.0Chronic persistent hepatitis, not elsewhere classified
K73.1Chronic lobular hepatitis, not elsewhere classified
K73.2Chronic active hepatitis, not elsewhere classified
K73.8Other chronic hepatitis, not elsewhere classified
K73.9Chronic hepatitis, unspecified
K74.0Hepatic fibrosis
K74.3Primary biliary cirrhosis
K74.4Secondary biliary cirrhosis
K74.5Biliary cirrhosis, unspecified
K74.60Unspecified cirrhosis of liver
K74.69Other cirrhosis of liver
K75.4Autoimmune hepatitis
K76.6Portal hypertension
K80.00Calculus of gallbladder with acute cholecystitis without obstruction
K80.01Calculus of gallbladder with acute cholecystitis with obstruction
K80.10Calculus of gallbladder with chronic cholecystitis without obstruction
K80.11Calculus of gallbladder with chronic cholecystitis with obstruction
K80.12Calculus of gallbladder with acute and chronic cholecystitis without obstruction
K80.13Calculus of gallbladder with acute and chronic cholecystitis with obstruction
K80.18Calculus of gallbladder with other cholecystitis without obstruction
K80.19Calculus of gallbladder with other cholecystitis with obstruction
K80.20Calculus of gallbladder without cholecystitis without obstruction
K80.21Calculus of gallbladder without cholecystitis with obstruction
K80.40Calculus of bile duct with cholecystitis, unspecified, without obstruction
K80.41Calculus of bile duct with cholecystitis, unspecified, with obstruction
K80.42Calculus of bile duct with acute cholecystitis without obstruction
K80.43Calculus of bile duct with acute cholecystitis with obstruction
K80.44Calculus of bile duct with chronic cholecystitis without obstruction
K80.45Calculus of bile duct with chronic cholecystitis with obstruction
K80.46Calculus of bile duct with acute and chronic cholecystitis without obstruction
K80.47Calculus of bile duct with acute and chronic cholecystitis with obstruction
K80.80Other cholelithiasis without obstruction
K80.81Other cholelithiasis with obstruction
K81.0Acute cholecystitis
K82.3Fistula of gallbladder
K83.3Fistula of bile duct
K85.0Idiopathic acute pancreatitis
K85.1Biliary acute pancreatitis
K85.2Alcohol induced acute pancreatitis
K85.3Drug induced acute pancreatitis
K85.8Other acute pancreatitis
K85.9Acute pancreatitis, unspecified
K86.0Alcohol-induced chronic pancreatitis
K86.1Other chronic pancreatitis
K86.2Cyst of pancreas
K86.3Pseudocyst of pancreas
K90.0Celiac disease
K90.1Tropical sprue
K90.2Blind loop syndrome, not elsewhere classified
K90.3Pancreatic steatorrhea
K90.4Malabsorption due to intolerance, not elsewhere classified
K90.81Whipple's disease
K90.89Other intestinal malabsorption
K90.9Intestinal malabsorption, unspecified
K91.2Postsurgical malabsorption, not elsewhere classified
K91.3Postprocedural intestinal obstruction
K91.5Postcholecystectomy syndrome
K91.81Other intraoperative complications of digestive system
K91.82Postprocedural hepatic failure
K91.83Postprocedural hepatorenal syndrome
K91.850Pouchitis
K91.858Other complications of intestinal pouch
K91.86Retained cholelithiasis following cholecystectomy
K91.89Other postprocedural complications and disorders of digestive system
K92.0Hematemesis
K92.1Melena
K92.2Gastrointestinal hemorrhage, unspecified
K92.81Gastrointestinal mucositis (ulcerative)
K94.03Colostomy malfunction
K94.13Enterostomy malfunction
K94.20Gastrostomy complication, unspecified
K94.21Gastrostomy hemorrhage
K94.22Gastrostomy infection
K94.23Gastrostomy malfunction
K94.29Other complications of gastrostomy
K94.30Esophagostomy complications, unspecified
K94.31Esophagostomy hemorrhage
K94.32Esophagostomy infection
K94.33Esophagostomy malfunction
K94.39Other complications of esophagostomy
L13.0Dermatitis herpetiformis
M34.0Progressive systemic sclerosis
M34.1CR(E)ST syndrome
M34.2Systemic sclerosis induced by drug and chemical
M34.81Systemic sclerosis with lung involvement
M34.82Systemic sclerosis with myopathy
M34.83Systemic sclerosis with polyneuropathy
M34.89Other systemic sclerosis
M34.9Systemic sclerosis, unspecified
Q26.5Anomalous portal venous connection
Q26.6Portal vein-hepatic artery fistula
Q27.33Arteriovenous malformation of digestive system vessel
Q39.0Atresia of esophagus without fistula
Q39.1Atresia of esophagus with tracheo-esophageal fistula
Q39.2Congenital tracheo-esophageal fistula without atresia
Q39.3Congenital stenosis and stricture of esophagus
Q39.4Esophageal web
Q39.5Congenital dilatation of esophagus
Q39.6Congenital diverticulum of esophagus
Q39.8Other congenital malformations of esophagus
Q39.9Congenital malformation of esophagus, unspecified
Q40.0Congenital hypertrophic pyloric stenosis
Q40.1Congenital hiatus hernia
Q40.2Other specified congenital malformations of stomach
Q40.3Congenital malformation of stomach, unspecified
R05Cough
R06.5Mouth breathing
R06.7Sneezing
R06.89Other abnormalities of breathing
R07.1Chest pain on breathing
R07.2Precordial pain
R07.81Pleurodynia
R07.82Intercostal pain
R07.89Other chest pain
R07.9Chest pain, unspecified
R09.82Postnasal drip
R10.0Acute abdomen
R10.10Upper abdominal pain, unspecified
R10.11Right upper quadrant pain
R10.12Left upper quadrant pain
R10.13Epigastric pain
R10.2Pelvic and perineal pain
R10.30Lower abdominal pain, unspecified
R10.31Right lower quadrant pain
R10.32Left lower quadrant pain
R10.33Periumbilical pain
R10.811Right upper quadrant abdominal tenderness
R10.812Left upper quadrant abdominal tenderness
R10.813Right lower quadrant abdominal tenderness
R10.814Left lower quadrant abdominal tenderness
R10.815Periumbilic abdominal tenderness
R10.816Epigastric abdominal tenderness
R10.817Generalized abdominal tenderness
R10.819Abdominal tenderness, unspecified site
R10.821Right upper quadrant rebound abdominal tenderness
R10.822Left upper quadrant rebound abdominal tenderness
R10.823Right lower quadrant rebound abdominal tenderness
R10.824Left lower quadrant rebound abdominal tenderness
R10.825Periumbilic rebound abdominal tenderness
R10.826Epigastric rebound abdominal tenderness
R10.827Generalized rebound abdominal tenderness
R10.829Rebound abdominal tenderness, unspecified site
R10.84Generalized abdominal pain
R10.9Unspecified abdominal pain
R11.0Nausea
R11.10Vomiting, unspecified
R11.11Vomiting without nausea
R11.12Projectile vomiting
R11.13Vomiting of fecal matter
R11.14Bilious vomiting
R11.2Nausea with vomiting, unspecified
R12Heartburn
R13.0Aphagia
R13.10Dysphagia, unspecified
R13.11Dysphagia, oral phase
R13.12Dysphagia, oropharyngeal phase
R13.13Dysphagia, pharyngeal phase
R13.14Dysphagia, pharyngoesophageal phase
R13.19Other dysphagia
R14.0Abdominal distension (gaseous)
R14.1Gas pain
R14.2Eructation
R14.3Flatulence
R15.0Incomplete defecation
R15.1Fecal smearing
R15.2Fecal urgency
R15.9Full incontinence of feces
R18.0Malignant ascites
R18.8Other ascites
R19.00Intra-abdominal and pelvic swelling, mass and lump, unspecified site
R19.01Right upper quadrant abdominal swelling, mass and lump
R19.02Left upper quadrant abdominal swelling, mass and lump
R19.03Right lower quadrant abdominal swelling, mass and lump
R19.04Left lower quadrant abdominal swelling, mass and lump
R19.05Periumbilic swelling, mass or lump
R19.06Epigastric swelling, mass or lump
R19.07Generalized intra-abdominal and pelvic swelling, mass and lump
R19.09Other intra-abdominal and pelvic swelling, mass and lump
R19.11Absent bowel sounds
R19.12Hyperactive bowel sounds
R19.15Other abnormal bowel sounds
R19.2Visible peristalsis
R19.5Other fecal abnormalities
R19.6Halitosis
R19.7Diarrhea, unspecified
R22.2Localized swelling, mass and lump, trunk
R47.82Fluency disorder in conditions classified elsewhere
R49.0Dysphonia
R49.21Hypernasality
R49.22Hyponasality
R49.8Other voice and resonance disorders
R63.0Anorexia
R63.3Feeding difficulties
R63.4Abnormal weight loss
R63.6Underweight
R64Cachexia
R68.84Jaw pain
R70.1Abnormal plasma viscosity
R74.8Abnormal levels of other serum enzymes
R74.9Abnormal serum enzyme level, unspecified
R77.0Abnormality of albumin
R77.1Abnormality of globulin
R77.2Abnormality of alphafetoprotein
R77.8Other specified abnormalities of plasma proteins
R77.9Abnormality of plasma protein, unspecified
R78.1Finding of opiate drug in blood
R78.2Finding of cocaine in blood
R78.3Finding of hallucinogen in blood
R78.4Finding of other drugs of addictive potential in blood
R78.5Finding of other psychotropic drug in blood
R78.6Finding of steroid agent in blood
R78.89Finding of other specified substances, not normally found in blood
R78.9Finding of unspecified substance, not normally found in blood
R79.89Other specified abnormal findings of blood chemistry
R93.3Abnormal findings on diagnostic imaging of other parts of digestive tract
R93.5Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum
S09.10XAUnspecified injury of muscle and tendon of head, initial encounter
S09.10XDUnspecified injury of muscle and tendon of head, subsequent encounter
S09.10XSUnspecified injury of muscle and tendon of head, sequela
S09.11XAStrain of muscle and tendon of head, initial encounter
S09.11XDStrain of muscle and tendon of head, subsequent encounter
S09.11XSStrain of muscle and tendon of head, sequela
S09.19XAOther specified injury of muscle and tendon of head, initial encounter
S09.19XDOther specified injury of muscle and tendon of head, subsequent encounter
S09.19XSOther specified injury of muscle and tendon of head, sequela
S09.8XXAOther specified injuries of head, initial encounter
S09.8XXDOther specified injuries of head, subsequent encounter
S09.8XXSOther specified injuries of head, sequela
S09.90XAUnspecified injury of head, initial encounter
S09.90XDUnspecified injury of head, subsequent encounter
S09.90XSUnspecified injury of head, sequela
S09.92XAUnspecified injury of nose, initial encounter
S09.92XDUnspecified injury of nose, subsequent encounter
S09.92XSUnspecified injury of nose, sequela
S09.93XAUnspecified injury of face, initial encounter
S09.93XDUnspecified injury of face, subsequent encounter
S09.93XSUnspecified injury of face, sequela
S11.20XAUnspecified open wound of pharynx and cervical esophagus, initial encounter
S11.20XDUnspecified open wound of pharynx and cervical esophagus, subsequent encounter
S11.20XSUnspecified open wound of pharynx and cervical esophagus, sequela
S11.21XALaceration without foreign body of pharynx and cervical esophagus, initial encounter
S11.21XDLaceration without foreign body of pharynx and cervical esophagus, subsequent encounter
S11.21XSLaceration without foreign body of pharynx and cervical esophagus, sequela
S11.22XALaceration with foreign body of pharynx and cervical esophagus, initial encounter
S11.22XDLaceration with foreign body of pharynx and cervical esophagus, subsequent encounter
S11.22XSLaceration with foreign body of pharynx and cervical esophagus, sequela
S11.23XAPuncture wound without foreign body of pharynx and cervical esophagus, initial encounter
S11.23XDPuncture wound without foreign body of pharynx and cervical esophagus, subsequent encounter
S11.23XSPuncture wound without foreign body of pharynx and cervical esophagus, sequela
S11.24XAPuncture wound with foreign body of pharynx and cervical esophagus, initial encounter
S11.24XDPuncture wound with foreign body of pharynx and cervical esophagus, subsequent encounter
S11.24XSPuncture wound with foreign body of pharynx and cervical esophagus, sequela
S11.25XAOpen bite of pharynx and cervical esophagus, initial encounter
S11.25XDOpen bite of pharynx and cervical esophagus, subsequent encounter
S11.25XSOpen bite of pharynx and cervical esophagus, sequela
S16.8XXAOther specified injury of muscle, fascia and tendon at neck level, initial encounter
S16.8XXDOther specified injury of muscle, fascia and tendon at neck level, subsequent encounter
S16.8XXSOther specified injury of muscle, fascia and tendon at neck level, sequela
S16.9XXAUnspecified injury of muscle, fascia and tendon at neck level, initial encounter
S16.9XXDUnspecified injury of muscle, fascia and tendon at neck level, subsequent encounter
S16.9XXSUnspecified injury of muscle, fascia and tendon at neck level, sequela
S19.80XAOther specified injuries of unspecified part of neck, initial encounter
S19.80XDOther specified injuries of unspecified part of neck, subsequent encounter
S19.80XSOther specified injuries of unspecified part of neck, sequela
S19.81XAOther specified injuries of larynx, initial encounter
S19.81XDOther specified injuries of larynx, subsequent encounter
S19.81XSOther specified injuries of larynx, sequela
S19.82XAOther specified injuries of cervical trachea, initial encounter
S19.82XDOther specified injuries of cervical trachea, subsequent encounter
S19.82XSOther specified injuries of cervical trachea, sequela
S19.83XAOther specified injuries of vocal cord, initial encounter
S19.83XDOther specified injuries of vocal cord, subsequent encounter
S19.83XSOther specified injuries of vocal cord, sequela
S19.84XAOther specified injuries of thyroid gland, initial encounter
S19.84XDOther specified injuries of thyroid gland, subsequent encounter
S19.84XSOther specified injuries of thyroid gland, sequela
S19.85XAOther specified injuries of pharynx and cervical esophagus, initial encounter
S19.85XDOther specified injuries of pharynx and cervical esophagus, subsequent encounter
S19.85XSOther specified injuries of pharynx and cervical esophagus, sequela
S19.89XAOther specified injuries of other specified part of neck, initial encounter
S19.89XDOther specified injuries of other specified part of neck, subsequent encounter
S19.89XSOther specified injuries of other specified part of neck, sequela
S19.9XXAUnspecified injury of neck, initial encounter
S19.9XXDUnspecified injury of neck, subsequent encounter
S19.9XXSUnspecified injury of neck, sequela
S27.812AContusion of esophagus (thoracic part), initial encounter
S27.812DContusion of esophagus (thoracic part), subsequent encounter
S27.812SContusion of esophagus (thoracic part), sequela
S27.813ALaceration of esophagus (thoracic part), initial encounter
S27.813DLaceration of esophagus (thoracic part), subsequent encounter
S27.813SLaceration of esophagus (thoracic part), sequela
S27.818AOther injury of esophagus (thoracic part), initial encounter
S27.818DOther injury of esophagus (thoracic part), subsequent encounter
S27.818SOther injury of esophagus (thoracic part), sequela
S27.819AUnspecified injury of esophagus (thoracic part), initial encounter
S27.819DUnspecified injury of esophagus (thoracic part), subsequent encounter
S27.819SUnspecified injury of esophagus (thoracic part), sequela
T18.100AUnspecified foreign body in esophagus causing compression of trachea, initial encounter
T18.100DUnspecified foreign body in esophagus causing compression of trachea, subsequent encounter
T18.100SUnspecified foreign body in esophagus causing compression of trachea, sequela
T18.108AUnspecified foreign body in esophagus causing other injury, initial encounter
T18.108DUnspecified foreign body in esophagus causing other injury, subsequent encounter
T18.108SUnspecified foreign body in esophagus causing other injury, sequela
T18.110AGastric contents in esophagus causing compression of trachea, initial encounter
T18.110DGastric contents in esophagus causing compression of trachea, subsequent encounter
T18.110SGastric contents in esophagus causing compression of trachea, sequela
T18.118AGastric contents in esophagus causing other injury, initial encounter
T18.118DGastric contents in esophagus causing other injury, subsequent encounter
T18.118SGastric contents in esophagus causing other injury, sequela
T18.120AFood in esophagus causing compression of trachea, initial encounter
T18.120DFood in esophagus causing compression of trachea, subsequent encounter
T18.120SFood in esophagus causing compression of trachea, sequela
T18.128AFood in esophagus causing other injury, initial encounter
T18.128DFood in esophagus causing other injury, subsequent encounter
T18.128SFood in esophagus causing other injury, sequela
T18.190AOther foreign object in esophagus causing compression of trachea, initial encounter
T18.190DOther foreign object in esophagus causing compression of trachea, subsequent encounter
T18.190SOther foreign object in esophagus causing compression of trachea, sequela
T18.198AOther foreign object in esophagus causing other injury, initial encounter
T18.198DOther foreign object in esophagus causing other injury, subsequent encounter
T18.198SOther foreign object in esophagus causing other injury, sequela
T18.2XXAForeign body in stomach, initial encounter
T18.2XXDForeign body in stomach, subsequent encounter
T18.2XXSForeign body in stomach, sequela
T18.3XXAForeign body in small intestine, initial encounter
T18.3XXDForeign body in small intestine, subsequent encounter
T18.3XXSForeign body in small intestine, sequela
T18.4XXAForeign body in colon, initial encounter
T18.4XXDForeign body in colon, subsequent encounter
T18.4XXSForeign body in colon, sequela
T18.8XXAForeign body in other parts of alimentary tract, initial encounter
T18.8XXDForeign body in other parts of alimentary tract, subsequent encounter
T18.8XXSForeign body in other parts of alimentary tract, sequela
T18.9XXAForeign body of alimentary tract, part unspecified, initial encounter
T18.9XXDForeign body of alimentary tract, part unspecified, subsequent encounter
T18.9XXSForeign body of alimentary tract, part unspecified, sequela
T28.0XXABurn of mouth and pharynx, initial encounter
T28.0XXDBurn of mouth and pharynx, subsequent encounter
T28.0XXSBurn of mouth and pharynx, sequela
T28.1XXABurn of esophagus, initial encounter
T28.1XXDBurn of esophagus, subsequent encounter
T28.1XXSBurn of esophagus, sequela
T28.2XXABurn of other parts of alimentary tract, initial encounter
T28.2XXDBurn of other parts of alimentary tract, subsequent encounter
T28.2XXSBurn of other parts of alimentary tract, sequela
T28.5XXACorrosion of mouth and pharynx, initial encounter
T28.5XXDCorrosion of mouth and pharynx, subsequent encounter
T28.5XXSCorrosion of mouth and pharynx, sequela
T28.6XXACorrosion of esophagus, initial encounter
T28.6XXDCorrosion of esophagus, subsequent encounter
T28.6XXSCorrosion of esophagus, sequela
T28.7XXACorrosion of other parts of alimentary tract, initial encounter
T28.7XXDCorrosion of other parts of alimentary tract, subsequent encounter
T28.7XXSCorrosion of other parts of alimentary tract, sequela
T54.0X3AToxic effect of phenol and phenol homologues, assault, initial encounter
T54.0X3DToxic effect of phenol and phenol homologues, assault, subsequent encounter
T54.0X3SToxic effect of phenol and phenol homologues, assault, sequela
T54.1X1AToxic effect of other corrosive organic compounds, accidental (unintentional), initial encounter
T54.1X1DToxic effect of other corrosive organic compounds, accidental (unintentional), subsequent encounter
T54.1X1SToxic effect of other corrosive organic compounds, accidental (unintentional), sequela
T54.1X2AToxic effect of other corrosive organic compounds, intentional self-harm, initial encounter
T54.1X2DToxic effect of other corrosive organic compounds, intentional self-harm, subsequent encounter
T54.1X2SToxic effect of other corrosive organic compounds, intentional self-harm, sequela
T54.1X3AToxic effect of other corrosive organic compounds, assault, initial encounter
T54.1X3DToxic effect of other corrosive organic compounds, assault, subsequent encounter
T54.1X3SToxic effect of other corrosive organic compounds, assault, sequela
T54.1X4AToxic effect of other corrosive organic compounds, undetermined, initial encounter
T54.1X4DToxic effect of other corrosive organic compounds, undetermined, subsequent encounter
T54.1X4SToxic effect of other corrosive organic compounds, undetermined, sequela
T54.2X3AToxic effect of corrosive acids and acid-like substances, assault, initial encounter
T54.2X3DToxic effect of corrosive acids and acid-like substances, assault, subsequent encounter
T54.2X3SToxic effect of corrosive acids and acid-like substances, assault, sequela
T54.3X1AToxic effect of corrosive alkalis and alkali-like substances, accidental (unintentional), initial encounter
T54.3X1DToxic effect of corrosive alkalis and alkali-like substances, accidental (unintentional), subsequent encounter
T54.3X1SToxic effect of corrosive alkalis and alkali-like substances, accidental (unintentional), sequela
T54.3X2AToxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, initial encounter
T54.3X2DToxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, subsequent encounter
T54.3X2SToxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, sequela
T54.3X3AToxic effect of corrosive alkalis and alkali-like substances, assault, initial encounter
T54.3X3DToxic effect of corrosive alkalis and alkali-like substances, assault, subsequent encounter
T54.3X3SToxic effect of corrosive alkalis and alkali-like substances, assault, sequela
T54.3X4AToxic effect of corrosive alkalis and alkali-like substances, undetermined, initial encounter
T54.3X4DToxic effect of corrosive alkalis and alkali-like substances, undetermined, subsequent encounter
T54.3X4SToxic effect of corrosive alkalis and alkali-like substances, undetermined, sequela
T54.91XAToxic effect of unspecified corrosive substance, accidental (unintentional), initial encounter
T54.91XDToxic effect of unspecified corrosive substance, accidental (unintentional), subsequent encounter
T54.91XSToxic effect of unspecified corrosive substance, accidental (unintentional), sequela
T54.92XAToxic effect of unspecified corrosive substance, intentional self-harm, initial encounter
T54.92XDToxic effect of unspecified corrosive substance, intentional self-harm, subsequent encounter
T54.92XSToxic effect of unspecified corrosive substance, intentional self-harm, sequela
T54.93XAToxic effect of unspecified corrosive substance, assault, initial encounter
T54.93XDToxic effect of unspecified corrosive substance, assault, subsequent encounter
T54.93XSToxic effect of unspecified corrosive substance, assault, sequela
T54.94XAToxic effect of unspecified corrosive substance, undetermined, initial encounter
T54.94XDToxic effect of unspecified corrosive substance, undetermined, subsequent encounter
T54.94XSToxic effect of unspecified corrosive substance, undetermined, sequela
T56.4X1AToxic effect of copper and its compounds, accidental (unintentional), initial encounter
T56.4X1DToxic effect of copper and its compounds, accidental (unintentional), subsequent encounter
T56.4X1SToxic effect of copper and its compounds, accidental (unintentional), sequela
T57.1X1AToxic effect of phosphorus and its compounds, accidental (unintentional), initial encounter
T57.1X1DToxic effect of phosphorus and its compounds, accidental (unintentional), subsequent encounter
T57.1X1SToxic effect of phosphorus and its compounds, accidental (unintentional), sequela
T57.1X2AToxic effect of phosphorus and its compounds, intentional self-harm, initial encounter
T57.1X2DToxic effect of phosphorus and its compounds, intentional self-harm, subsequent encounter
T57.1X2SToxic effect of phosphorus and its compounds, intentional self-harm, sequela
T57.1X3AToxic effect of phosphorus and its compounds, assault, initial encounter
T57.1X3DToxic effect of phosphorus and its compounds, assault, subsequent encounter
T57.1X3SToxic effect of phosphorus and its compounds, assault, sequela
T57.1X4AToxic effect of phosphorus and its compounds, undetermined, initial encounter
T57.1X4DToxic effect of phosphorus and its compounds, undetermined, subsequent encounter
T57.1X4SToxic effect of phosphorus and its compounds, undetermined, sequela
T65.5X1AToxic effect of nitroglycerin and other nitric acids and esters, accidental (unintentional), initial encounter
T65.5X1DToxic effect of nitroglycerin and other nitric acids and esters, accidental (unintentional), subsequent encounter
T65.5X1SToxic effect of nitroglycerin and other nitric acids and esters, accidental (unintentional), sequela
T66.XXXARadiation sickness, unspecified, initial encounter
T66.XXXDRadiation sickness, unspecified, subsequent encounter
T66.XXXSRadiation sickness, unspecified, sequela
T86.40Unspecified complication of liver transplant
T86.41Liver transplant rejection
T86.42Liver transplant failure
T86.43Liver transplant infection
T86.49Other complications of liver transplant
Z43.1Encounter for attention to gastrostomy
Z72.4Inappropriate diet and eating habits
Z79.01Long term (current) use of anticoagulants
Z79.1Long term (current) use of non-steroidal anti-inflammatories (NSAID)
Z79.3Long term (current) use of hormonal contraceptives
Z79.891Long term (current) use of opiate analgesic
Z79.899Other long term (current) drug therapy
Z83.71Family history of colonic polyps
Z83.79Family history of other diseases of the digestive system
Z85.00Personal history of malignant neoplasm of unspecified digestive organ
Z85.01Personal history of malignant neoplasm of esophagus
Z85.028Personal history of other malignant neoplasm of stomach
Z85.068Personal history of other malignant neoplasm of small intestine
Z85.07Personal history of malignant neoplasm of pancreas
Z85.09Personal history of malignant neoplasm of other digestive organs
Z86.010Personal history of colonic polyps
Z87.11Personal history of peptic ulcer disease
Z87.19Personal history of other diseases of the digestive system

Policy:

Horizon BCBSNJ will not recognize the application of Modifier 59 when applied to colonoscopy services 45380, 45382, or 45386 when performed with another colonoscopy
service (CPT® code 45380, 45382, 45383, 45384, 45385, 45386 or 45387) on the same date of service for the same patient by the same provider.

Regardless of the application of modifier 59, Horizon BCBSNJ will only consider for reimbursement that colonoscopy service (CPT code 45380, 45382, 45383, 45384, 45385,
45386 or 45387) with the highest RVU

CPT code 45381 performed on the same date of service for the same patient by the same provider as another colonoscopy service (CPT code 45380, 45382, 45383, 45384,
45385, 45386 or 45387) and appropriately appended with Modifier 59, will be considered for reimbursement at 50% of Horizon BCBSNJ’s allowance.

Procedure:

Recognize the application of Modifier 59 appropriately appended to CPT code 45381 when billed on the same date of service, for the same patient, by the same provider as another colonoscopy service (CPT code 45380, 45382, 45383, 45384, 45385, 45386 or 45387) and consider CPT code 45381 for reimbursement at 50% of Horizon BCBSNJ’s applicable allowance.

Do not recognize the application of Modifier 59 for colonoscopy services (CPT code 45380, 45382, or 45386) when billed together with another colonoscopy service (CPT code 45380, 45382, 45383, 45384, 45385, 45386 or 45387) for the same date of service, same patient, by the same provider.


Regardless of the application of modifier 59, Horizon BCBSNJ will only consider for reimbursement that colonoscopy service (CPT code 45380, 45382, 45383, 45384,
45385, 45386 or 45387) with the highest RVU. The other colonoscopy service(s) will not be considered for separate reimbursement but rather will deny as incidental or mutually exclusive to the colonoscopy service considered for reimbursement.

CPT/HCPCS Codes

77051Computer dx mammogram add-on
77052Comp screen mammogram add-on
77055Mammogram one breast
77056Mammogram both breasts
77057Mammogram screening
77063Breast tomosynthesis bi
G0202Screeningmammographydigital
G0204Diagnosticmammographydigital
G0206Diagnosticmammographydigital
G0279Tomosynthesis, mammo

Screening Mammogram

A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection breast cancer,and includes a physician’s interpretation of the results of the procedure. A screening mammogram does not require a physician’s referral, however, detection of a radiographic abnormality, may prompt the interpreting radiologist to order additional views on the same day. When this is the case, the mammography is no longer considered to be a screening exam and should be reported as a diagnostic mammogram. Radiologists who order additional tests must refer back to the treating physician or qualified non-physician practitioner for his/her UPIN and report back to the treating physician the condition of the patient. No separate reimbursement will be made for additional views. The cost for additional views is included in the cost of the diagnostic mammography service. Screening mammogram(s) (digital and non-digital) for the following indications are allowed:

Asymptomatic women ages 40 and older are eligible for a screening mammography (digital and non-digital) performed after at least 11 months have passed following the month in which the last screening mammography was performed.

Women between the ages of 35 and 39 are eligible to receive one baseline screening mammogram.

Women with breast implants are eligible for screening mammography when the screening mammogram is performed within the aforementioned age and frequency limitations.
Services will only be allowed if supplied by certified suppliers or FDA-certified mammography centers.

Limitations

The screening mammogram must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.

Payment may not be made for a screening mammography performed on a woman under age 35.
Payment may be made for only one screening mammography performed on a woman over age 34, but under age 40.

Screening mammograms performed prior to 11 months lapsing following the month in which the last screening mammography service was rendered is noncovered.

Facilities that perform screening mammography services may not release screening mammography x-rays for interpretation to physicians who are not approved under the facility’s certification number unless the patient has requested a transfer of the films from one facility to another for a second opinion or the patient has moved to another part of the country where the next screening mammography will be performed.

Diagnostic Mammography

A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician’s interpretation of the results of the procedure.

Diagnostic mammogram(s) are allowed for the following indications:

-the patient is under the care of the referring/ordering physician or qualified non-physician practitioner;
-there are signs and/or symptoms suggestive of malignancy (mass, some types of spontaneous nipple discharge or skin changes);
-there are possible radiographic abnormalities detected on screening mammography;
-there is short interval follow-up (less than one year) necessary for unresolved clinical/radiographic concerns; or
-follow-up of established history of a malignancy is necessary

Diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease. These diagnoses should not, however, routinely warrant a diagnostic mammography.

A breast implant does not necessarily imply that a mammogram is diagnostic in nature. Although additional views may be needed, these additional views do not necessarily constitute a diagnostic mammogram, unless there are specific findings that require investigation.

Medicare Part B covers diagnostic mammography services if they are furnished by a facility that meets the certification requirements of section 354 of the Public Health Service Act (PHS Act), as implemented by 21 CFR part 900, subpart B. As of October 1, 1994, the Mammography Quality Standards Act requires that all mammography centers that bill Medicare be certified by the Food and Drug Administration (FDA). Only FDA-certified mammography centers will be reimbursed.

A physician (or qualified non-physician practitioner) referral is required for diagnostic mammography. The patient must be under the care of the physician (or qualified non-physician practitioner) who orders the procedure. The order should specify the diagnosis prompting the referral for a diagnostic mammogram.

Diagnostic mammography should be performed under the direct, on-site supervision of an interpreting physician qualified in mammography. Diagnostic mammography may require that the performing radiologist review the history with the patient, review the prior mammograms, and perform an examination as part of the mammography. Also, the findings of the examination are typically discussed with the patient at the completion of the mammogram. Therefore, if telemammography is being used with digital diagnostic mammography, the radiologist need not be present for the mammography; however, he/she must be available to discuss the history with the patient, examine the patient, and discuss results of the findings of the examination with the patient within an acceptable period of time.

Limitations

This policy does not outline complete indications and limitations of breast ultrasound but addresses the limitations of screening mammography with breast ultrasound. (There is no Medicare benefit.)

Breast ultrasound is not a Medicare preventive services benefit. Therefore, routine breast cancer screening with ultrasound (including patients with dense breast tissue) is not a Medicare covered service. Clinical evidence has not yet demonstrated that routine use of ultrasonography as an adjunct to screening mammography reduces the mortality rate from breast cancer.

Breast ultrasonography may be reasonable and necessary in addition to a diagnostic mammography for the evaluation of some ambiguous mammographic or palpable masses, focal asymmetry, or dense breast tissue that may represent or mask a mass. Breast ultrasonography may also be performed for non-palpable masses, detected by mammography, to differentiate cysts from solid lesions.

Breast ultrasound is medically reasonable and necessary as an aid for radiologists to localize breast lesions and in guiding placement of instruments for cyst aspiration and percutaneous breast biopsies. (This is not an all-inclusive list.) If breast ultrasound is medically reasonable and necessary and done on the same day as a screening mammography, the screening mammography becomes diagnostic.

The request (order) for the ultrasound examination must be originated by a treating physician/NPP. This requirement is not applicable to hospital based radiologists for inpatient or outpatient breast ultrasound.

A radiologist performing a therapeutic interventional procedure is considered a treating physician. A radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician.

If the testing facility has no order for breast ultrasound and cannot reach the treating physician/practitioner to obtain a new order for the addition of breast ultrasound when needed and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply:

The testing center performs the mammography ordered by the treating physician/practitioner;

The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;

Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary;

The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary; and

The interpreting physician at the testing facility documents in his/her report why additional testing was done.

Breast sonography should be performed under the general supervision of a physician qualified in breast ultrasonography.

The ultrasound study must have a permanent written record along with the accompanying set of images in retrievable image storage format. The images and report should become a part of the patient’s permanent medical record.

Revenue Codes
CodeDescription

0400Other Imaging Services - General Classification
0401Other Imaging Services - Diagnostic Mammography
0403Other Imaging Services - Screening Mammography
0521Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0524Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF or Skilled Swing Bed in a Covered Part A Stay


For screening mammography (77057, 77063 or G0202):

For claims with dates of service on or after January 1, 2002, when a screening mammography and a diagnostic mammography are performed on the same date of service, for the same patient, append modifier -GG to the diagnostic mammography procedure code. Both the screening mammography and the diagnostic mammography procedure codes should be reported on the same claim:

Group 1 Codes
Z12.31*Encounter for screening mammogram for malignant neoplasm of breast


For diagnostic mammography (77055, 77056, G0204, G0206 or G0279) billed with or without Modifier GG:


C43.52Malignant melanoma of skin of breast
C43.59Malignant melanoma of other part of trunk
C44.501Unspecified malignant neoplasm of skin of breast
C44.509Unspecified malignant neoplasm of skin of other part of trunk
C44.511Basal cell carcinoma of skin of breast
C44.519Basal cell carcinoma of skin of other part of trunk
C44.521Squamous cell carcinoma of skin of breast
C44.529Squamous cell carcinoma of skin of other part of trunk
C44.591Other specified malignant neoplasm of skin of breast
C44.599Other specified malignant neoplasm of skin of other part of trunk
C45.9Mesothelioma, unspecified
C50.011Malignant neoplasm of nipple and areola, right female breast
C50.012Malignant neoplasm of nipple and areola, left female breast
C50.019Malignant neoplasm of nipple and areola, unspecified female breast
C50.021Malignant neoplasm of nipple and areola, right male breast
C50.022Malignant neoplasm of nipple and areola, left male breast
C50.029Malignant neoplasm of nipple and areola, unspecified male breast
C50.111Malignant neoplasm of central portion of right female breast
C50.112Malignant neoplasm of central portion of left female breast
C50.119Malignant neoplasm of central portion of unspecified female breast
C50.121Malignant neoplasm of central portion of right male breast
C50.122Malignant neoplasm of central portion of left male breast
C50.129Malignant neoplasm of central portion of unspecified male breast
C50.211Malignant neoplasm of upper-inner quadrant of right female breast
C50.212Malignant neoplasm of upper-inner quadrant of left female breast
C50.219Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.221Malignant neoplasm of upper-inner quadrant of right male breast
C50.222Malignant neoplasm of upper-inner quadrant of left male breast
C50.229Malignant neoplasm of upper-inner quadrant of unspecified male breast
C50.311Malignant neoplasm of lower-inner quadrant of right female breast
C50.312Malignant neoplasm of lower-inner quadrant of left female breast
C50.319Malignant neoplasm of lower-inner quadrant of unspecified female breast
C50.321Malignant neoplasm of lower-inner quadrant of right male breast
C50.322Malignant neoplasm of lower-inner quadrant of left male breast
C50.329Malignant neoplasm of lower-inner quadrant of unspecified male breast
C50.411Malignant neoplasm of upper-outer quadrant of right female breast
C50.412Malignant neoplasm of upper-outer quadrant of left female breast
C50.419Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.421Malignant neoplasm of upper-outer quadrant of right male breast
C50.422Malignant neoplasm of upper-outer quadrant of left male breast
C50.429Malignant neoplasm of upper-outer quadrant of unspecified male breast
C50.511Malignant neoplasm of lower-outer quadrant of right female breast
C50.512Malignant neoplasm of lower-outer quadrant of left female breast
C50.519Malignant neoplasm of lower-outer quadrant of unspecified female breast
C50.521Malignant neoplasm of lower-outer quadrant of right male breast
C50.522Malignant neoplasm of lower-outer quadrant of left male breast
C50.529Malignant neoplasm of lower-outer quadrant of unspecified male breast
C50.611Malignant neoplasm of axillary tail of right female breast
C50.612Malignant neoplasm of axillary tail of left female breast
C50.619Malignant neoplasm of axillary tail of unspecified female breast
C50.621Malignant neoplasm of axillary tail of right male breast
C50.622Malignant neoplasm of axillary tail of left male breast
C50.629Malignant neoplasm of axillary tail of unspecified male breast
C50.811Malignant neoplasm of overlapping sites of right female breast
C50.812Malignant neoplasm of overlapping sites of left female breast
C50.819Malignant neoplasm of overlapping sites of unspecified female breast
C50.821Malignant neoplasm of overlapping sites of right male breast
C50.822Malignant neoplasm of overlapping sites of left male breast
C50.829Malignant neoplasm of overlapping sites of unspecified male breast
C50.911Malignant neoplasm of unspecified site of right female breast
C50.912Malignant neoplasm of unspecified site of left female breast
C50.919Malignant neoplasm of unspecified site of unspecified female breast
C50.921Malignant neoplasm of unspecified site of right male breast
C50.922Malignant neoplasm of unspecified site of left male breast
C50.929Malignant neoplasm of unspecified site of unspecified male breast
C56.1Malignant neoplasm of right ovary
C56.2Malignant neoplasm of left ovary
C56.9Malignant neoplasm of unspecified ovary
C77.3Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
C78.00Secondary malignant neoplasm of unspecified lung
C78.01Secondary malignant neoplasm of right lung
C78.02Secondary malignant neoplasm of left lung
C78.1Secondary malignant neoplasm of mediastinum
C78.2Secondary malignant neoplasm of pleura
C78.7Secondary malignant neoplasm of liver and intrahepatic bile duct
C79.2Secondary malignant neoplasm of skin
C79.31Secondary malignant neoplasm of brain
C79.32Secondary malignant neoplasm of cerebral meninges
C79.40Secondary malignant neoplasm of unspecified part of nervous system
C79.49Secondary malignant neoplasm of other parts of nervous system
C79.51Secondary malignant neoplasm of bone
C79.52Secondary malignant neoplasm of bone marrow
C79.60Secondary malignant neoplasm of unspecified ovary
C79.61Secondary malignant neoplasm of right ovary
C79.62Secondary malignant neoplasm of left ovary
C79.81Secondary malignant neoplasm of breast
C80.0Disseminated malignant neoplasm, unspecified
C80.1Malignant (primary) neoplasm, unspecified
D03.52Melanoma in situ of breast (skin) (soft tissue)
D03.59Melanoma in situ of other part of trunk
D04.5Carcinoma in situ of skin of trunk
D05.00Lobular carcinoma in situ of unspecified breast
D05.01Lobular carcinoma in situ of right breast
D05.02Lobular carcinoma in situ of left breast
D05.10Intraductal carcinoma in situ of unspecified breast
D05.11Intraductal carcinoma in situ of right breast
D05.12Intraductal carcinoma in situ of left breast
D05.80Other specified type of carcinoma in situ of unspecified breast
D05.81Other specified type of carcinoma in situ of right breast
D05.82Other specified type of carcinoma in situ of left breast
D05.90Unspecified type of carcinoma in situ of unspecified breast
D05.91Unspecified type of carcinoma in situ of right breast
D05.92Unspecified type of carcinoma in situ of left breast
D22.5Melanocytic nevi of trunk
D23.5Other benign neoplasm of skin of trunk
D24.1Benign neoplasm of right breast
D24.2Benign neoplasm of left breast
D24.9Benign neoplasm of unspecified breast
D48.5Neoplasm of uncertain behavior of skin
D48.60Neoplasm of uncertain behavior of unspecified breast
D48.61Neoplasm of uncertain behavior of right breast
D48.62Neoplasm of uncertain behavior of left breast
D49.1Neoplasm of unspecified behavior of respiratory system
D49.2Neoplasm of unspecified behavior of bone, soft tissue, and skin
D49.3Neoplasm of unspecified behavior of breast
D49.6Neoplasm of unspecified behavior of brain
D49.7Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
I80.8Phlebitis and thrombophlebitis of other sites
M70.80Other soft tissue disorders related to use, overuse and pressure of unspecified site
M70.88Other soft tissue disorders related to use, overuse and pressure other site
M70.89Other soft tissue disorders related to use, overuse and pressure multiple sites
M70.90Unspecified soft tissue disorder related to use, overuse and pressure of unspecified site
M70.98Unspecified soft tissue disorder related to use, overuse and pressure other
M70.99Unspecified soft tissue disorder related to use, overuse and pressure multiple sites
M79.5Residual foreign body in soft tissue
M79.81Nontraumatic hematoma of soft tissue
M79.89Other specified soft tissue disorders
M79.9Soft tissue disorder, unspecified
N60.01Solitary cyst of right breast
N60.02Solitary cyst of left breast
N60.09Solitary cyst of unspecified breast
N60.11Diffuse cystic mastopathy of right breast
N60.12Diffuse cystic mastopathy of left breast
N60.19Diffuse cystic mastopathy of unspecified breast
N60.21Fibroadenosis of right breast
N60.22Fibroadenosis of left breast
N60.29Fibroadenosis of unspecified breast
N60.31Fibrosclerosis of right breast
N60.32Fibrosclerosis of left breast
N60.39Fibrosclerosis of unspecified breast
N60.41Mammary duct ectasia of right breast
N60.42Mammary duct ectasia of left breast
N60.49Mammary duct ectasia of unspecified breast
N60.81Other benign mammary dysplasias of right breast
N60.82Other benign mammary dysplasias of left breast
N60.89Other benign mammary dysplasias of unspecified breast
N60.91Unspecified benign mammary dysplasia of right breast
N60.92Unspecified benign mammary dysplasia of left breast
N60.99Unspecified benign mammary dysplasia of unspecified breast
N61Inflammatory disorders of breast
N62Hypertrophy of breast
N63Unspecified lump in breast
N64.0Fissure and fistula of nipple
N64.1Fat necrosis of breast
N64.2Atrophy of breast
N64.3Galactorrhea not associated with childbirth
N64.4Mastodynia
N64.51Induration of breast
N64.52Nipple discharge
N64.53Retraction of nipple
N64.59Other signs and symptoms in breast
N64.81Ptosis of breast
N64.82Hypoplasia of breast
N64.89Other specified disorders of breast
N64.9Disorder of breast, unspecified
N65.0Deformity of reconstructed breast
N65.1Disproportion of reconstructed breast
R59.0Localized enlarged lymph nodes
R59.1Generalized enlarged lymph nodes
R59.9Enlarged lymph nodes, unspecified
R92.0Mammographic microcalcification found on diagnostic imaging of breast
R92.1Mammographic calcification found on diagnostic imaging of breast
R92.2Inconclusive mammogram
R92.8Other abnormal and inconclusive findings on diagnostic imaging of breast
R93.9Diagnostic imaging inconclusive due to excess body fat of patient
S20.00XAContusion of breast, unspecified breast, initial encounter
S20.01XAContusion of right breast, initial encounter
S20.02XAContusion of left breast, initial encounter
S21.001AUnspecified open wound of right breast, initial encounter
S21.002AUnspecified open wound of left breast, initial encounter
S21.009AUnspecified open wound of unspecified breast, initial encounter
S21.011ALaceration without foreign body of right breast, initial encounter
S21.012ALaceration without foreign body of left breast, initial encounter
S21.019ALaceration without foreign body of unspecified breast, initial encounter
S21.021ALaceration with foreign body of right breast, initial encounter
S21.022ALaceration with foreign body of left breast, initial encounter
S21.029ALaceration with foreign body of unspecified breast, initial encounter
S21.031APuncture wound without foreign body of right breast, initial encounter
S21.032APuncture wound without foreign body of left breast, initial encounter
S21.039APuncture wound without foreign body of unspecified breast, initial encounter
S21.041APuncture wound with foreign body of right breast, initial encounter
S21.042APuncture wound with foreign body of left breast, initial encounter
S21.049APuncture wound with foreign body of unspecified breast, initial encounter
S21.051AOpen bite of right breast, initial encounter
S21.052AOpen bite of left breast, initial encounter
S21.059AOpen bite of unspecified breast, initial encounter
S28.211AComplete traumatic amputation of right breast, initial encounter
S28.212AComplete traumatic amputation of left breast, initial encounter
S28.219AComplete traumatic amputation of unspecified breast, initial encounter
S28.221APartial traumatic amputation of right breast, initial encounter
S28.222APartial traumatic amputation of left breast, initial encounter
S28.229APartial traumatic amputation of unspecified breast, initial encounter
S29.001AUnspecified injury of muscle and tendon of front wall of thorax, initial encounter
S29.009AUnspecified injury of muscle and tendon of unspecified wall of thorax, initial encounter
S29.091AOther injury of muscle and tendon of front wall of thorax, initial encounter
S29.099AOther injury of muscle and tendon of unspecified wall of thorax, initial encounter
S29.8XXAOther specified injuries of thorax, initial encounter
S29.9XXAUnspecified injury of thorax, initial encounter
S39.001AUnspecified injury of muscle, fascia and tendon of abdomen, initial encounter
S39.091AOther injury of muscle, fascia and tendon of abdomen, initial encounter
S39.81XAOther specified injuries of abdomen, initial encounter
S39.91XAUnspecified injury of abdomen, initial encounter
T85.41XABreakdown (mechanical) of breast prosthesis and implant, initial encounter
T85.42XADisplacement of breast prosthesis and implant, initial encounter
T85.43XALeakage of breast prosthesis and implant, initial encounter
T85.44XACapsular contracture of breast implant, initial encounter
T85.49XAOther mechanical complication of breast prosthesis and implant, initial encounter
T85.79XAInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter
Z03.89Encounter for observation for other suspected diseases and conditions ruled out
Z08Encounter for follow-up examination after completed treatment for malignant neoplasm
Z77.123Contact with and (suspected) exposure to radon and other naturally occuring radiation
Z77.128Contact with and (suspected) exposure to other hazards in the physical environment
Z77.9Other contact with and (suspected) exposures hazardous to health
Z85.3Personal history of malignant neoplasm of breast
Z85.831Personal history of malignant neoplasm of soft tissue
Z85.89Personal history of malignant neoplasm of other organs and systems
Z91.89Other specified personal risk factors, not elsewhere classified
Z92.89Personal history of other medical treatment
Z98.82Breast implant status
Z98.86Personal history of breast implant removal

Coverage
Coverage guidelines for colonoscopies are dependent upon the type of service being rendered.

Diagnostic and Surgical Endoscopy

A diagnostic endoscopy is a covered service if it is proven to be medically reasonable and necessary to the overall diagnosis and treatment of the patient’s condition. Services are considered medically necessary when they meet one or more of the following requirements:

• Are proper and needed for the diagnosis or treatment of the patient’s medical condition
• Are furnished for the diagnosis, direct care, and treatment of the patient’s medical condition
• Meet the standards of good medical practice
• Are not mainly for the convenience of the patient, provider, or supplier

Screening Colonoscopy

Medicare provides coverage of a screening colonoscopy for all beneficiaries regardless to age. A doctor of medicine or osteopathy must perform this screening.

• Beneficiaries at high risk for developing colorectal cancer: Medicare provides coverage of a screening colonoscopy once every two years for beneficiaries at
high risk for colorectal cancer.

• Beneficiaries not at high risk for developing colorectal cancer: Medicare provides coverage of a screening colonoscopy once every 10 years but not
within 47 months of a previous screening sigmoidoscopy.