Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A58428 (Billing and Coding: Diagnostic Colonoscopy) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A58428: Billing and Coding: Diagnostic Colonoscopy (Billing and Coding, effective 2026-02-04)
- Covered ICD-10-CM codes
- 244
- 1 group
- Non-covered ICD-10-CM codes
- 1
- Procedure codes listed
- 29
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| A09 | Infectious gastroenteritis and colitis, unspecified |
| C18.0 | — |
| C18.1 | — |
| C18.2 | — |
| C18.3 | — |
| C18.4 | — |
| C18.5 | — |
| C18.6 | — |
| C18.7 | — |
| C18.8 | — |
| C19 | Malignant neoplasm of rectosigmoid junction |
| C20 | Malignant neoplasm of rectum |
| C21.1 | — |
| C21.2 | — |
| C21.8 | — |
| C46.4 | — |
| C49.A4 | — |
| C49.A5 | — |
| C49.A9 | — |
| C78.5 | — |
| C80.0 | — |
| C82.09 | — |
| C82.19 | — |
| C82.29 | — |
Procedure codes: 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398.
Coverage indications, limitations and medical necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
History/Background and/or General Information
Colonoscopy allows direct visual examination of the intestinal tract with a flexible tube containing light transmitting glass fibers that return a magnified image. Colonoscopy can act as both a diagnostic and therapeutic tool in the same procedure. Therapeutic indications include removal of polyps or foreign bodies, hemostasis by coagulation, and removal of tumors.
Covered Indications
A diagnostic colonoscopy will be considered medically reasonable and necessary under any of the following circumstances:
• Evaluation of an abnormality (e.g. barium enema), which is likely to be clinically significant, such as a filling defect or stricture. 1
• Evaluation and excision of polyps detected by barium enema or flexible sigmoidoscopy, computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), and positron emission tomography (PET). 2
• Evaluation of unexplained gastrointestinal bleeding; hematochezia not thought to be from rectum or perianal source, melena of unknown origin, or presence of fecal occult blood. 1
• Unexplained iron deficiency anemia. 1
• Examination to evaluate the entire colon for simultaneous cancer or neoplastic polyps in a patient with a treatable cancer or neoplastic polyp. 1 The term treatable cancer may include not only curative intent, but also procedures done to prolong survival, progression free disease, and quality of life/palliative care.
• Evaluation of a patient with carcinoma of the colon before bowel resection.
• Post-surgical colonoscopy should be conducted at 1 year, if normal then subsequent examination should be at 3 years, if normal then subsequent examination should be at 5 years. 1,4
• Yearly evaluation with multiple biopsies for detection of cancer and dysplasia in patients with chronic ulcerative colitis who have had pancolitis of greater than seven years duration. 4
• Yearly evaluation with multiple biopsies for detection of cancer and dysplasia in patients with chronic ulcerative colitis who have had left-sided colitis of over 15 years duration. 4
• Evaluation in patients with chronic inflammatory bowel disease of the colon when more precise diagnosis or determination of the extent of activity of disease will influence immediate management. 1,4
• Evaluation of clinically significant diarrhea of unexplained origin. 1
• Evaluation and treatment of bleeding from lesions such as vascular anomalies, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy). 1,3
• Detection and removal of foreign bodies. 1
• Evaluation and decompression treatment of acute non-toxic megacolon. 1
• Evaluation and balloon dilation treatment of stenotic lesions (e.g., anastomotic strictures). 1
• Evaluation and decompression of colonic volvulus. 1
• Examination and evaluation when a change in management is probable or is being suspected based on results of the colonoscopy. 1
• Evaluation within 6 months of the removal of sessile polyps to determine and document total excision.
• If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 months.
• After evidence of total excision without return of the polyp.
• Unsuccessful colonoscopy preoperatively due to obstructive cancer,
• repeat colonoscopy 3-6 months post-operatively unless unresectable metastases are found at surgery. 4
• Evaluation to differentiate between ulcerative and Crohn's colitis. 1
• Evaluation 3 years after resection of newly diagnosed small (
• After 1 negative 3-year follow-up examination subsequent surveillance intervals may be increased to 5 years. 4
• Evaluation at 1 and 4 year intervals after resection of multiple or large (> 10mm) adenomatous polyps.
• Subsequent surveillance intervals may then be increased to every 5 years. 4
• Evaluation in 1 year after the removal of multiple adenomas.
• If examination proves negative then repeat in 3 years.
• After 1 negative 3-year follow-up examination, repeat exam every 5 years. 2
• Evaluation of a patient presenting with signs/symptoms (e.g., rectal bleeding, abdominal pain) of a disorder that appears to be related to the colon. 1
Limitations
Notice: 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.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.
• Diagnostic colonoscopy is not indicated in patients with chronic ulcerative colitis who have had left-sided colitis of over 15 years duration when disease is limited to the rectosigmoid colon.
Summary of evidence (opening)
Indications for diagnostic colonoscopy are based on guidelines from a variety of specialty societies and government organizations. Diagnostic testing is typically done to confirm or rule out a condition in an individual who is symptomatic or who is believed to have a specific condition.
In 2012, the American Society for Gastrointestinal Endoscopy (ASGE) Standards Practice Committee published recommendations for the appropriate use of GI endoscopy. 1 “This is a position statement that discusses the use of GI endoscopy in clinical situations.” “These ASGE recommendations are based on critical review of available information and broad clinical consensus” and recommends diagnostic colonoscopy for individuals with various circumstances and symptoms, in which colonoscopy is required for definitive diagnosis and treatment. Colonoscopy is generally indicated for the evaluation of an abnormality on barium enema or other imaging study that is likely to be clinically significant. Some of these abnormalities may include such abnormalities as a filling defect, an evaluation of unexplained GI bleeding, unexplained iron deficiency anemia, screening and surveillance for colonic neoplasia, for dysplasia and cancer surveillance in select patients with long-standing ulcerative colitis or Crohn’s colitis, evaluation of patients with chronic inflammatory bowel disease if more precise diagnosis or determination of the extent of activity of disease will influence management, and for clinically significant diarrhea of unexplained origin. These are only a few of the clinically significant abnormalities indicated for colonoscopy. However, guidelines are intended to provide information to assist endoscopists in providing care to their patients and varying clinical considerations may require a different course of action that may vary from the guideline.
In 2000, Bond JH and the American Journal of Gastroenterology published the Polyp Guideline: Diagnosis, Treatment, and Surveillance for Patients with Colorectal Polyps. 2 These practice guidelines were developed to indicate the preferable approaches to the management of patients with colorectal polyps based on the available scientific evidence as colonoscopy is the most accurate method of detecting polyps of all sizes and allows for immediate biopsy or polypectomy. These guidelines indicate patients who have polyps detected by various methods should have a colonoscopy to examine the entire colon, excise the polyp(s) and search for additional neoplasms. Patients who have had excision of a large sessile polyp should have a follow-up colonoscopy in 3-6 months. If residual polyp is present, it should be resected and another 3-6 month follow-up colonoscopy should be performed to check for completeness of resection. If complete resection is not possible after two or three examinations, the patient should be referred for surgical therapy. Patients with polyps detected by barium enema or flexible sigmoidoscopy should undergo colonoscopy to excise the polyp and search for additional neoplasms. After one negative follow-up colonoscopy, subsequent surveillance intervals may be increased to 5 years.
Green et al. 3 2005, is a prospective randomized study consisting of 50 patients with “lower gastrointestinal bleeding but without upper or anorectal bleeding sources.” Patients were randomized into two groups (colonoscopy and standards of care algorithm). According to the findings a definite source of bleeding was found more often in the urgent colonoscopy patients than in the standard care group. There was no difference in outcomes among the two groups with regards to mortality, hospital stay, ICU stay, transfusion requirements, early or late rebleeding. The study demonstrates “patients with substantial lower gastrointestinal hemorrhage, outcomes are similar whether urgent colonoscopy or expectant colonoscopy is performed as part of a standard of care algorithm.” Except for diagnosis, urgent colonoscopy provided no advantage over radiographic intervention. Based on the findings, it is suggested that the type of approach should be based on local expertise and available resources.
The contractor cites 7 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2021-03-21
- Current revision effective
- 2021-03-21
- MCD version
- 7
The contractor lists one National Coverage Determination as related: NCD 100.2 Endoscopy. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Novitas Solutions, Inc. hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L38812 cover?
Colonoscopy allows direct visual examination of the intestinal tract with a flexible tube containing light transmitting glass fibers that return a magnified image. Colonoscopy can act as both a diagnostic and therapeutic tool in the same procedure. Therapeutic indications include removal of polyps or foreign bodies, hemostasis by coagulation, and removal of tumors. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L38812 apply to?
Novitas Solutions, Inc. applies it to Medicare claims in AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L38812?
The companion billing and coding article A58428 lists 244 ICD-10-CM codes in 1 group that support medical necessity and 1 that do not; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L38812?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.