K38.3 — Fistula of appendix
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- All services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.
- An Advance Beneficiary Notice (ABN), Form CMS-R-131, should be signed by the beneficiary when applicable to indicate acceptance of financial responsibility.
- The patient's medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.
Key Coverage Criteria
- Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
- A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
- Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, or inadequate exam).
- Evaluation of unexplained gastrointestinal bleeding, including hematochezia not thought to be from a rectal/perianal source or melena of unknown origin, is covered.
- Colonoscopy is covered for investigation of a positive fecal occult blood test.
- Evaluation of unexplained iron deficiency anemia is covered when colon evaluation is clinically indicated.
6 Active Policies
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
A56456 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
A56632 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
L34415 — CT of the Abdomen and Pelvis
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.