K60.411 — Rectal fistula, simple, initial
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When performed for surveillance of colonic neoplasia, report the appropriate CPT/HCPCS procedure code and the appropriate primary ICD-10-CM code plus one of the following secondary diagnosis codes: Z85.038, Z85.048, Z86.0100, Z86.0101, Z86.0102, or Z86.0109.
- For high-risk post-surgical follow-up at 1 year (with continued 24-month screening eligibility), report HCPCS code G0105 as the appropriate screening/high-risk colonoscopy code.
- The patient's medical record must fully support the medical necessity for TRUS and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
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.
- Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
- TRUS is covered for evaluation of suspected prostatitis or suspected prostatic abscess.
- TRUS is covered to evaluate congenital or acquired cystic conditions of the prostate, seminal vesicles, and related tissues.
- Transrectal ultrasound (TRUS) is covered for clinical staging of proven prostate cancer when radical prostatectomy or radiation therapy is being considered.
4 Active Policies
A57427 — Billing and Coding: Transrectal Ultrasound
J06
L33578 — Transrectal Ultrasound
J06
A56632 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related Codes
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