N32.1 — Vesicointestinal fistula
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
- Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
- Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
- 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.
Key Coverage Criteria
- 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.
- 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).
6 Active Policies
A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic
J05
L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic
J05
A56456 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
A56632 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related Codes
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