K64.8 — Other hemorrhoids
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.
- Supportive clinical documentation evidencing the condition and treatment must be in the clinical notes or procedure note and made available upon request to the MAC or other authorized CMS auditor.
- Medical records need not be submitted with the claim unless modifier -22 is used, but must be furnished to Medicare upon request and must support medical reasonableness, necessity, frequency, and substantiate the diagnosis listed on the claim.
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.
- A colonoscopy may be billed when a sigmoidoscope is used only if the bowel is sufficiently short that the entire colon can be examined and this fact is clearly documented in the clinical record.
- An incomplete colonoscopy (inability to advance the colonoscope to the cecum or colon‑small intestine anastomosis due to unforeseen circumstances) is billed using codes 44388, 45378, G0105 or G0121 with modifier -53.
- When the colonoscopy procedure is unusual or difficult, report modifier -22 (unusual procedural services) on the claim.
- A follow-on screening colonoscopy after a Medicare-covered non-invasive stool-based CRC screening test that is positive is included in a Complete Colorectal Cancer (CRC) Screening and should be billed as such with modifier -KX to confirm clinical requirements are met.
6 Active Policies
A57343 — Billing and Coding: Diagnostic and Therapeutic Colonoscopy
A56632 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
A57342 — Billing and Coding: Diagnostic and Therapeutic Colonoscopy
L34213 — Diagnostic and Therapeutic Colonoscopy
L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related Codes
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