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FUTURE Local Coverage Determination (LCD): UPPER GASTROINTESTINAL ENDOSCOPY (DIAGNOSTIC AND THERAPEUTIC) (L35350)

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Contractor Information

Contractor Name Novitas Solutions, Inc.

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Contract Number 04412

LCD Information

Document Information

Contract Type A and B MAC

Jurisdiction J - H

L35350

LCD ID

Original ICD-9 LCD ID L34745

Jurisdiction Texas

Original Effective Date

LCD Title

For services performed on or after 10/01/2015

UPPER GASTROINTESTINAL ENDOSCOPY (DIAGNOSTIC

AND THERAPEUTIC)

Revision Effective Date

For services performed on or after 10/01/2015 AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ("AHA"), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA." Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company.

CMS National Coverage Policy Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

These endoscopic examinations may be used to evaluate symptoms, identify anatomic abnormalities, to obtain biopsies, or are employed for therapeutic reasons. Most often the procedure is performed by a fiberoptic endoscope (including video endoscopy), a flexible tube containing light transmitting glass fibers that return a magnified image directly or by video.

INDICATIONS:

These procedures can only be allowed if abnormal signs or symptoms or known disease are present.

A. Indications which support EGD(s) for diagnostic purpose(s) are as follows:

? Upper abdominal distress which persists despite an appropriate trial of therapy; ? Upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g.,

prolonged anorexia and weight loss); ? Dysphagia or odynophagia; ? Esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy; ? Persistent vomiting of unknown cause; ? Other systemic diseases in which the presence of upper GI pathology might modify other planned

management. Examples include patients with a history of GI bleeding who are scheduled for organ transplantation; long term anticoagulation; and chronic non-steroidal therapy for arthritis; ? X-ray findings of:

A suspected neoplastic lesion, for confirmation and specific histologic diagnosis; Gastric or esophageal ulcer; or Evidence of upper gastrointestinal tract stricture or obstruction. ? The presence of gastrointestinal bleeding: In most actively bleeding patients or those recently stopped; When surgical therapy is contemplated; When re-bleeding occurs after acute self-limited blood loss or after endoscopic therapy; When portal hypertension or aorto-enteric fistula is suspected; or For presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative. ? When sampling of duodenal or jejunal tissue or fluid is indicated;

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? To assess acute injury after caustic agent ingestion; or ? Intraoperative EGD when necessary to clarify location or pathology of a lesion.

B. Indications which support EGD(s) for therapeutic purpose(s) are as follows:

? Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy);

? Sclerotherapy for bleeding from esophageal or proximal gastric varices or banding of varices; ? Foreign body removal; ? Removal of selected polypoid lesions; ? Placement of feeding tubes (oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic

jejunostomy); ? Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing

guidewires); or ? Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement).

C. Sequential or periodic diagnostic upper GI endoscopy may be indicated for an appropriate number of procedures for active or symptomatic conditions.

? For follow-up of selected esophageal, gastric or stomal ulcers to demonstrate healing (frequency of followup EGDs is variable, but every two to four months until healing is demonstrated is reasonable);

? For follow-up in patients with prior adenomatous gastric polyps (approximate frequency of follow-up EGDs would be every one to four years depending on the clinical circumstances, with occasional patients with sessile polyps requiring every six-month surveillance initially);

? For follow-up for adequacy of prior sclerotherapy or banding of esophageal varices (approximate frequency of follow-up EGDs is very variable depending on the state of the patient but every six to twentyfour months is reasonable after the initial sclerotherapy/banding sessions are completed);

? For follow-up of Barrett's esophagus (approximate frequency of follow-up EGDs is one to two years with biopsies, unless dysplasia or atypia is demonstrated, in which case a repeat biopsy in two to three months might be indicated); or

? For follow-up in patients with familial adenomatous polyposis (approximate frequency of follow-up EGDs would be every two to four years, but might be more frequent, such as every six to twelve months if gastric adenomas or adenomas of the duodenum were demonstrated).

D. The endoscopic retrograde cholangiopancreatography (ERCP) procedure is generally indicated for certain biliary and pancreatic conditions.

? ERCP is generally not indicated for the diagnosis of pancreatitis except for gallstone pancreatitis; ? ERCP is not usually indicated in early stages or in acute pancreatitis and could possibly exacerbate it; ? ERCP may be useful in traumatic pancreatitis to accurately localize the injury and provide endoscopic

drainage; ? ERCP may be useful in pancreatic duct stricture evaluation; ? ERCP may be useful for the extraction of bile duct stones in severe gallstone induced pancreatitis; ? ERCP may be useful in detecting pancreatic ductal changes in chronic pancreatitis and also the presence of

calcified stones in the ductal system. A pancreatogram may be performed and is likely to be abnormal in chronic alcoholic pancreatitis but less so in non-alcoholic induced types; ? ERCP may be useful in detecting gallstones in symptomatic patients whose oral cholecytogram and gallbladder ultrasonograms are normal; and ? ERCP may be indicated in patients with radiologic imaging suggestive of common bile duct stones or other potential pathology.

LIMITATIONS:

1. Indications for which EGD(s) are generally not covered by Medicare are as follows:

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? Distress which is chronic, non-progressive, atypical for known organic disease, and is considered functional in origin (there are occasional exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy);

? Uncomplicated heartburn responding to medical therapy; ? Metastatic adenocarcinoma of unknown primary site when the results will not alter management; ? X-ray findings of:

asymptomatic or uncomplicated sliding hiatus hernia; uncomplicated duodenal bulb ulcer which has responded to therapy; or Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy; ? Routine screening of the upper gastrointestinal tract; ? Patients without current gastrointestinal symptoms about to undergo elective surgery for non-upper gastrointestinal disease; or ? When lower G.I. endoscopy reveals the cause of symptoms, abnormal signs or laboratory tests (e.g., colonic neoplasm with iron deficiency anemia). Exceptions can be considered if medical necessity for this procedure can be demonstrated.

2. Sequential or periodic diagnostic EGD is not indicated for:

? Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, treated achalasia, or prior gastric operation;

? Surveillance of healed benign disease such as esophagitis, gastric or duodenal ulcer; or ? Surveillance during chronic repeated dilations of benign strictures unless there is a change in status.

3. These services may be performed in a physician's office, or in a hospital inpatient or outpatient, or an ASC.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Chapter 13, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

? Safe and effective. ? Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates

of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary). ? Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.

Furnished in a setting appropriate to the patient's medical needs and condition.

Ordered and furnished by qualified personnel. One that meets, but does not exceed, the patient's medical needs. At least as beneficial as an existing and available medically

appropriate alternative.

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Coding Information

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Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes Group 1 Paragraph: This policy does not take precedence over the Correct Coding Initiative (CCI). Consult current correct coding guidelines for applicable specific code combinations or reductions in payment due to specific codes billed.

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes: 43191 Esophagoscopy rigid trnso dx 43192 Esophagoscp rig trnso inject 43193 Esophagoscp rig trnso biopsy 43194 Esophagoscp rig trnso rem fb 43195 Esophagoscopy rigid balloon 43196 Esophagoscp guide wire dilat 43197 Esophagoscopy flex dx brush 43198 Esophagosc flex trnsn biopsy 43200 Esophagoscopy flexible brush 43201 Esoph scope w/submucous inj 43202 Esophagoscopy flex biopsy 43204 Esoph scope w/sclerosis inj 43205 Esophagus endoscopy/ligation 43206 Esoph optical endomicroscopy 43211 Esophagoscop mucosal resect 43212 Esophagoscop stent placement 43213 Esophagoscopy retro balloon 43214 Esophagosc dilate balloon 30 43215 Esophagoscopy flex remove fb 43216 Esophagoscopy lesion removal 43217 Esophagoscopy snare les remv 43220 Esophagoscopy balloon 43235 Egd diagnostic brush wash

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43236 Uppr gi scope w/submuc inj 43237 Endoscopic us exam esoph 43238 Egd us fine needle bx/aspir 43239 Egd biopsy single/multiple 43240 Egd w/transmural drain cyst 43241 Egd tube/cath insertion 43242 Egd us fine needle bx/aspir 43243 Egd injection varices 43244 Egd varices ligation 43245 Egd dilate stricture 43246 Egd place gastrostomy tube 43247 Egd remove foreign body 43248 Egd guide wire insertion 43249 Esoph egd dilation ................
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