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ICD-10-CM Z85.030, Personal history of malignant carcinoid tumor of large intestine | No Prior Auth

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`Z85.030`, Personal history of malignant carcinoid tumor of large intestine

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

The submitted CPT/HCPCS code must accurately describe the service performed.
All documentation must be maintained in the patient medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).

The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.

The submitted medical record must support the use of the selected ICD-10-CM code(s).

Medical record documentation (office/progress notes) maintained by the ordering or referring physician must indicate the medical necessity of the colonoscopy procedure.

Key Coverage Criteria

Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
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.
Initial MRD testing is covered for patients with cancer when baseline tumor profiling from a prior analysis is utilized, using listed bespoke/plasma-series MRD tests (e.g., Signatera Bespoke Assay Design + Plasma Series Bundle, RaDaR Bespoke Assay Design + Plasma Series Bundle, Oncodetect Bespoke Assay Design + Plasma Test Bundle, Guardant Reveal MRD Bundle, Guardant360 Response).
Subsequent MRD testing for patients with cancer is covered only if there is clinical evidence of an a priori change in tumor genetic content in accordance with NCD 90.2.

20 Active Policies

CGS-J15-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J15

CGS-J15-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J15

CGS-J18-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J18

CGS-J18-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J18

WPS-J5-L34614, Colonoscopy and Sigmoidoscopy-Diagnostic

J5

A56394, Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J5

WPS-J5-L38835, MolDX: Minimal Residual Disease Testing for Cancer

J5

A58468, Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

J5

WPS-J5-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J5

A58756, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J5

A59915, Billing and Coding: Pharmacogenomic Testing

J6

NGS-J6-L39995, Pharmacogenomic Testing

J6

WPS-J8-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J8

WPS-J8-L34614, Colonoscopy and Sigmoidoscopy-Diagnostic

J8

WPS-J8-L38835, MolDX: Minimal Residual Disease Testing for Cancer

J8

A55937, Billing and Coding: Diagnostic Colonoscopy

J9

FIRST_COAST-L39073, Pharmacogenomics Testing

J9

FIRST_COAST-L33671, Diagnostic Colonoscopy

J9

A58812, Billing and Coding: Pharmacogenomics Testing

J9

NOVITAS-JH-L39063, Pharmacogenomics Testing

JH

Related Codes

Z85.040(20 policies)C19(20 policies)Z85.038(20 policies)C20(20 policies)C18.9(18 policies)C18.3(17 policies)C18.2(17 policies)C18.4(17 policies)

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