D12.5 — Benign neoplasm of sigmoid colon
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The submitted CPT/HCPCS code must accurately describe the service performed.
- All documentation must be maintained in the patient medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
Key Coverage Criteria
- Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
- Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
- Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
- A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- Genetic testing for Lynch syndrome is covered when the patient meets the reasonable and necessary clinical criteria specified in LCD L34912.
20 Active Policies
A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic
J05
L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic
J05
L36850 — Peripheral Nerve Blocks
J06
A57452 — Billing and Coding: Peripheral Nerve Blocks
J06
L33671 — Diagnostic Colonoscopy
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.