Z86.012 — Personal history of benign carcinoid tumor
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.
- Document imaging reports (e.g., barium enema, CT, or other imaging) showing the abnormality prompting colonoscopy.
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 is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect or stricture).
- Colonoscopy is covered for evaluation of unexplained gastrointestinal bleeding presenting as hematochezia not thought to be from a rectal or perianal source.
- Colonoscopy is covered for melena of unknown origin after an upper GI source has been excluded.
2 Active Policies
A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic
J05
L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic
J05
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