K60.519 — Anorectal fistula, simple, unspecified
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.
- When performing endoscopy for indications that are generally not covered, submit additional documentation evidencing the medical necessity of the procedure for review.
- Provider/supplier must notify the beneficiary in writing prior to rendering the service if the provider is aware the test/procedure may not be covered by Medicare; limitation of liability and refund requirements apply when denials are likely.
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 to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, inadequate exam).
- Evaluation of unexplained gastrointestinal bleeding including hematochezia not thought to be from a rectal/perianal source, melena of unknown origin, or presence of fecal occult blood.
- Evaluation of unexplained iron deficiency anemia.
- Surveillance examination of the entire colon to evaluate for synchronous colonic cancer or polyps in a patient with treatable cancer or polyps.
2 Active Policies
A56632 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
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