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CodeMap® LCD-L34005


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LCD for Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy (L34005)
See related Articles:
A56456-Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

Contractor Information

Contractor Name: CGS Administrators, LLC - Full list of policies of this Medicare Contractor

Contractor Number: 15102

Contractor Type: MAC B

LCD Information

LCD ID Number: L34005 Status: A-Approved

LCD Title: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

Geographic Jurisdiction: Kentucky Other Jurisdictions

Original Determination Effective Date: 10/01/2015

Original Determination Ending Date:

Revision Effective Date: 01/26/2023

Revision End Date:

CMS National Coverage Policy:

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

    30.1B Incomplete colonoscopies being billed and paid for using CPT code 45378 with modifier 53

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

    20.4.6 Payment due to unusual circumstances (Modifiers 22 and 52)

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 18:

    60.2 Colorectal Cancer Screening HCPCS Codes, Frequency Requirements, and Age Requirements (If Applicable)


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All information on this web site is compiled directly from information obtained from the Center for Medicare and Medicaid Services (CMS) and from its Contractors.

CodeMap® has made every reasonable effort to ensure the accuracy of the information contained on this web site. However, the ultimate responsibility for correct coding and claims submission lies with the provider of services. CodeMap® makes no representation, warranty, or guarantee that this compilation of Medicare information is error-free or that the use of this information will result in Medicare coverage and subsequent payment of claims. Final coverage and payment of claims are subject to many factors exclusively controlled by CMS and its contractors.

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09/22/2023 02:33:02

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