ARCHIVED


Medical Policy

Policy Num:      06.001.030
Policy Name:    ENDOSCOPIC ULTRASONOGRAPHY
Policy ID:          [06.001.030]  [Ar / L / M+ / P-]   [0.00.00]

ARCHIVED

Last Review:       August 23, 2023
Next Review:      Policy Archived
 

Related Policies: None

 ENDOSCOPIC ULTRASONOGRAPHY

Population Reference No. Populations Interventions Comparators Outcomes

1

Individuals:

  • With need to drain cysts

Interventions of interest are:

  •  Endoscopic ultrasound

Comparators of interest are:

  • Conventional imaging

Relevant outcomes include:

  • Benefits and harms

Summary

Endoscopic ultrasonography (EUS) has evolved from a diagnostic imaging modality to one that can also be used for invasive diagnostic and therapeutic procedures. These advances are largely due to the introduction of linear scanning instruments that can be used to place devices into the ultrasound plane of view, permitting various interventions to be performed. The ability of EUS to guide a biopsy needle into lesions that are too small to be identified by computed tomography or magnetic resonance imaging, or too well encased by surrounding vascular structures to allow percutaneous biopsy, secures its role in a variety of clinical settings.

Indications for EUS-guided fine-needle aspiration (EUS-FNA) include biopsy of mucosal and submucosal lesions in which prior conventional endoscopic biopsies have been nondiagnostic. The procedure is most commonly used to sample peri-intestinal structures such as lymph nodes and masses in the pancreas, liver, adrenal gland, and bile duct. It has also been used to aspirate peritoneal and pleural fluid.

Endoscopic ultrasonography is used to establish the stages of tumors of the gastrointestinal track, pancreas and biliary ducts, being its main use to establish the stages of esophageal, gastric and rectal tumors. Some studies have shown that Endoscopic Sonography is the most exact imaging modality to determine the depth of the tumor invasion with a preoperative certainty between 80 to 90%, when compared with a histological specimen. Using ultrasound endoscopic sonography it cannot be distinguished with certainty whether the process is inflammatory or neoplastic. Likewise, ultrasonographic sonography has proved to be ineffective in determining the stages of lymphatic nodules, for the nodule had to be localized and identified as benign or malign.

Objective

The objective of this  evidence review is to determine the appropriateness of endoscopic ultrasound  when used for drainage of biopsy procedures.

Policy Statements

Endoscopic ultrasonography is considered for payment, as recommended by the American Society for Gastrointestinal Endoscopy (ASGE) and the American  Gastroenterological Association for the following indications:

  1. Establish the stages of gastrointestinal tract tumors (including the esophagus,  pancreas and biliary ducts;
  2. Evaluate anomalies on the gastrointestinal walls or adjacent structures.
  3. Obtain tissue of organs adjacent to the gastrointestinal wall.
  4. Evaluate anomalies in the pancreas, including masses, pseudocysts and chronic pancreatitis;
  5. Evaluate anomalies of the biliary tract;
  6. Provide endoscopic therapies under sonographic control;
  7. Evaluation of adenopathies and mases in the mediastenium
  8. Establish stages of lung cancer (Endoscopic Sonography with aspiration with a fine needle)
  9. Evaluation of gastric subephitelial masses

Ultrasonographic endoscopy is not considered for payment to establish the stages of tumors which have been proved methastatic through other means.

Policy Guidelines

At present, therapeutic EUS should be limited to tertiary centers with experienced endoscopists, interventional radiologists, and surgeons.

Benefit Application

BlueCard/National Account Issues

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

 Endoscopic ultrasound (EUS) was developed as a diagnostic modality but rapidly gained a role for a variety of therapeutic applications. EUS has been used increasingly for drainage of pancreatic pseudocysts, treatment of cystic lesions of the pancreas, EUS-guided cholangiopancreatography, localized therapy for pancreatic tumors, and treatment of subepithelial lesions and gastric varices

Regulatory Status

Does not apply

Rationale

The efficacy and safety of therapeutic endoscopic ultrasound (EUS) is evolving. It has been used for drainage of pancreatic pseudocysts, treatment of cystic and neuroendocrine neoplasms of the pancreas, EUS-guided cholangiopancreatography, localized therapy for pancreatic tumors, and treatment of subepithelial lesions and gastric varices

Population Reference No. 1 

Individuals with need to drain cysts. Intervention of interest are endoscopic ultrasound. Comparators ofinterest are Conventional imaging. Relevant  outcomes include Benefits and harms

Population

Reference No. 1

Policy Statement

 [X] MedicallyNecessary [ ] Investigational

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

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  2. Caletti G, Odegaard S, Rosch T, et al. Endoscopic ultrasonography: A summary of the conclusion of the working party for the tenth World Congress of Gastroenterology.  Am J Gastroenterol.  1994; 89: S138-S143.
  3. Lux G, Heyder N. Endoscopic ultrasonography of the pancreas: Technical aspects. Scand J Gastroenterol.
  4. Nickl NJ, Cotton PB. Clinical application of endoscopic ultrsonography. Am J Gastroenterol. 1990; 85: 675-682.
  5. Sivak MV, Kafman A. Endoscopic ultrasonography in the differential diagnosis of pancreatic disease: A preliminary report. Scan J Gastroenterol. 1986; 21    (suppl 123): 130-134.
  6. Roubein LE. Endoscopic ultrasonography in diagnosis and staging of pancreatic cancer. Dig Dis Sci. 1995; 41: 613-615.
  7. Nakaizuma A, Uehara H, Iishi H, et al. Endoscopic ultrsonography in diagnosis and staging of pancreatic cancer.  Dig Dis Sci. 1995; 40: 696-700.
  8. Tio TL, Tygat GN, Cikot RJ, et al. Ampullopancreatic carcinoma: Preoperative TNM classification with endosonography.  Radiology. 1990; 175(2): 455-461.
  9. Rosch T, Lightdale CJ, Botet JF, et al. Localization of pancreatic endocrine tumors by endoscopic ultrasonography. N Eng J Med. 1992; 326: 1721-1726.
  10. American Society for Gastrointestinal Endoscopy (ASGE). Appropriate Use of Gastrointestinal Endoscopy. Manchester, MA: ASGE, 1999. Available at: http://www.asge.org./index.jsp. Accessed April 18, 2000.
  11. Gilbert DA, DiMarino AJ, Jensen DM, et al. Status evaluation: Endoscopio ultrasonography.  American Society for Gastroenterology Endoscopy. Technology Assessment Committee.  Gastrointest Endosc. 1992; 38(6): 747-749.
  12. No authors listed. Technology status evaluation: Endoscopic ultrasonography: Update November 1997. ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 1998; 48 (6): 705-707.
  13. DeVita VT Jr, Hellman S, Rosenburg SA, eds. Cancer Principles & Practice of Oncology. 5th ed. Philadelphia, PA: Lippincott-Raven; 1997:699-701.
  14. Cho E, Nakajima M, Yasuda K, et al. Recatal carcinoid tumor: Endoscopio ultrasonography in the diagnosis of colorectal cancer invasión.  Gastrointest Endosc. 1993;39(4):521-527.
  15. Shimizu S, Tada M, Kawai K. Use of endoscopic ultrasonography for the diagnosis of colorectal tumors.  Endoscopy. 1990; 22(1): 31-34.
  16. Fujishima H, Misawa T, Maruoka A, et al. Rectal carcinoid tumor: Endoscopic ultrasonographic detection and endoscopic removal. Eur J Radiol. 1993; 16(3): 198-200.
  17. Romano G, Belli G, Rotondano G. Colorectal cancer. Diagnosis of recurrence. Gastrointest Endosc Clin N Am. 1995; 5(4): 831-841.
  18. Miyazaki S. Diagnosis of colorectal tumor invasion by endoscopic miniature probe ultrasonography. Kurume Med J. 1998; 45(1): 95-103.
  19. Yoshida M, Tsukamoto Y, Niwa Y, et al. Endoscopio assessment of invasión of colorectal tumors with a new high-frequency ultrasound probe. Gastrointest Endosc, 1995; 41(6): 587-592.
  20. Eisen GM, Dominitz JA, Faigel DO, et al. An annotated algorithmic approach to malignant billiary obstruction. Gastrointest Endosc. 2001; 53 (7): 849-852.
  21. Byrne MF, Jowell PS. Gastrointestinal imaging: Endoscopic ultrasound. Gastroenterology. 2002; 122(6): 1631-1648.
  22. Levy MJ, Wiersema MJ. Endoscopic ultrasound in the diagnosis and staging of pancreatic cancer. Oncology (Huntingt). 2002; 16(1): 29-38, 43; discussion 44, 47-49, 53-56.
  23. Fusaroli P, Caletti G. Endoscopio ultrasonography. Endoscopy. 2003; 35(2):   127-135.
  24. Cannizzaro R, Fornasarig M, Lacchin T. Endoscopio diagnosis and staging of gastric tumors. Suppl Tumori. 2003; 2(5): S16-S18.
  25. Jacobson BC, Hirota W, Baron TH, et al. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc. 2003; (57)7: 817-822.
  26. Berger AC, Scott WJ. Noninvasive staging of esophageal carcinoma. J Surg Res. 2004; 117(1): 127-133.
  27. Giovannini M. Ultrasound-guided endoscopic surgery.  Best Pract Res Clin Gastroenterol. 2004; 18(1): 183-200.
  28. Worrell S, Horvath K, Blakemore T, Flum D. Endorectal ultrasound detection of focal carcinoma within rectal adenomas. Am J Surg. 2004; 187(5): 625-629; discussion 629.
  29. Shirakawa T, Imamura F, Hamamoto J, et al. Usefulness of endobronchial ultrasonography for transbronchial lung biopsies of peripheral lung lesions. Respiration. 2004; 71(3): 260-268.
  30. Herth FJ. Mediastinal staging--the role of endobronchial and endo-oesophageaL sonographic guided needle aspiration. Lung Cancer. 2004; 45 Suppl 2:S63-S67.
  31. Kramer H, van Putten JW, et al. Oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer. Thorax. 2004: 59(7): 596-601.
  32. Wallace MB, Woodward TA, Raimondo M. Endoscopic ultrasound and staging of non-small cell lung cancer. Gastrointest Endosc Clin N Am. 2005; 15(1): 157-167, x.
  33. Kramer H, van Putten JW, Douma WR, et al. Technical description of endoscopic ultrasonography with fine-needle aspiration for the staging of lung cancer. Respir Med. 2005; 99(2): 179-185.
  34. Sreenarasinhaiah J. The emerging role of endoscopic ultrsonography in cancer staging. Am J Med Sci. 2005; 329(5): 247-258.
  35. Adler DG, Jacobson BC, Davila RE, et al. ASGE guideline: Complications of EUS. Gastrointest Endosc. 2005; 61(1): 8-12.
  36. Jacobson BC, Hirota WK, Goldstein JL, et al. The role of EUS for evaluation of mediastinal adenopathy. Gastrointest Endosc. 2003; 58(6): 819-821.
  37. Davila RE, Rajan E, Adler D, et al. ASGE guideline: the role of endoscopy in the diagnosis, staging and management of colorectal cancer. Gastrointest Endosc. 2005; 61(1): 1-7.
  38. Jacobson BC, Baron TH, Adler DG, et al. ASGE guideline: the role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory fluid collections of the pancreas. Gastrointest Endosc. 2005; 61(3): 363-370.
  39. Jacobson BC, Hirota W, Baron TH, et al. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc. 2003; 57(7): 817-822.
  40. Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with lung cancer. A national clinical guideline. SIGN Publication No. 80. Edinburgh, Scotland: SIGN; February 2005.
  41. Society for Surgery of the Alimentary Tract (SSAT). Surgical treatment of esophageal cancer. Manchester, MA: Society for Surgery of the Alimentary Tract (SSAT); 2002.
  42. Baron TH, Mallery JS, Hirota WK, et al. the role of endoscopy in the evaluation and treatment of patients with pancreaticobiliary malignancy. Gastrointest Endosc. 2003; 58(5): 643-649.
  43. Annema JT, Versteegh MI, Veselic M, et al. Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of lung cancer and its impact on surgical staging. J Clin Oncol. 2005; 23(33): 8357-8361.
  44. Pedrazzani C, Bernini M, Giacopuzzi S, et al. Evaluation of Siewert classification in gastroesophageal junction adenocarcinoma: What is the role of endoscopic ultrasonography? J Surg Oncol. 2005; 91(4): 226-231.
  45. Liu CL, Fan ST, Lo CM, et al. Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: A prospective reandomized study.  Clin Gastroenterol Hepatol. 2005; 3(12): 1238-1244.
  46. Herth FJ, Eberhardt R, Becker HD, Ernst A. Endobronchial ultrasound-guided transbronchial lung biopsy in fluoroscopically invisible solitary pulmonary nodules: A prospective trail. Chest 2006; 129(1): 147-150.
  47. Thomas-Marques L, Murat A, Delemer B, et al. Prospective endoscopic ultrasonographic evaluation of the frequency of nonfunctioning pancreaticoduodenal endocrine tumors in patients with multiple endocrine neoplasia type 1. Am J Gastroenterol. 2006; 101(2): 266-273.
  48. Current Procedural terminology(2016) American Medical Association
  49. Kim JH, Lee YC, Kim H, et al. Endoscopic resection for undifferentiated early gastric cancer. Gastrointest Endosc 2009; 69:e1.
  50. Tamegai Y, Saito Y, Masaki N, et al. Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy 2007; 39:418.
  51. Park CH, Cheon JH, Kim JO, et al. Criteria for decision making after endoscopic resection of well-differentiated rectal carcinoids with regard to potential lymphatic spread. Endoscopy 2011; 43:790.
  52. Savides TJ. Endoscopic Ultrasonography. In: Gastrointestinal submucosal masses, 1, Gress F (Eds), Blackwell Science, 2001.

 

Codes

CODES

NUMBER

 

CPT

43231

Esophagoscopy with endoscopic ultrasound examination
 

43232

Esophagoscopy with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)     

 

43237

Esophagoscopy with endoscopic ultrasound examination limited to the esophagus

 

43238

Esophagoscopy with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (included endoscopic ultrasound examination limited to the esophagus)
 

43242

Esophagoscopy with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and or jejunum as appropriate)
 

43259

Esophagoscopy with endoscopic ultrasound examination, including, the esophagus, stomach, and either the duodenum and/or jejunum as appropriate
 

  45341 

Protosigmoidoscopy with endoscopic ultrasound examination
 

  45342 

Protosigmoidoscopy with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
 

45391

Colonoscopy with endoscopy ultrasound examination
 

45392

Colonoscopy with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
 

76975

Gastrointestinal endoscopic ultrasound, supervision and interpretation

ICD-10-CM

B25.2

Cytomegaloviral pancreatitis
 

C15.3

Malignant neoplasm of upper third of esophagus
 

C15.4

Malignant neoplasm of middle third of esophagus
 

C15.5

Malignant neoplasm of lower third of esophagus
 

C15.8

Malignant neoplasm of overlapping sites of esophagus
 

C15.9

Malignant neoplasm of esophagus, unspecified
 

C16.0

Malignant neoplasm of cardia
 

C16.1

Malignant neoplasm of fundus of stomach
 

C16.2

Malignant neoplasm of body of stomach
 

C16.3

Malignant neoplasm of pyloric antrum
 

C16.4

Malignant neoplasm of pylorus
 

C16.5

Malignant neoplasm of lesser curvature of stomach, unspecified
 

C16.6

Malignant neoplasm of greater curvature of stomach, unspecified
 

C16.8

Malignant neoplasm of overlapping sites of stomach
 

C16.9

Malignant neoplasm of stomach, unspecified
 

C17.0

Malignant neoplasm of duodenum
 

C17.1

Malignant neoplasm of jejunum
 

C17.2

Malignant neoplasm of ileum
 

C17.3

Meckels diverticulum, malignant
 

C17.8

Malignant neoplasm of overlapping sites of small intestine
 

C17.9

Malignant neoplasm of small intestine, unspecified
 

C18.0

Malignant neoplasm of cecum
 

C18.1

Malignant neoplasm of appendix
 

C18.2
Malignant neoplasm of ascending colon
 

C18.3


Malignant neoplasm of hepatic flexure
 

C18.4


Malignant neoplasm of transverse colon
 

C18.5


Malignant neoplasm of splenic flexure
 

C18.6


Malignant neoplasm of descending colon
 

C18.7


Malignant neoplasm of sigmoid colon
 

C18.8


Malignant neoplasm of overlapping sites of colon
 

C18.9


Malignant neoplasm of colon, unspecified
 

C19


Malignant neoplasm of rectosigmoid junction
 

C20


Malignant neoplasm of rectum
 

C21.0


Malignant neoplasm of anus, unspecified
 

C21.1


Malignant neoplasm of anal canal
 

C21.2


Malignant neoplasm of cloacogenic zone
 

C21.8


Malignant neoplasm of overlapping sites of rectum, anus and anal canal
 

C22.0


Liver cell carcinoma
 

C22.1


Intrahepatic bile duct carcinoma
 

C22.2


Hepatoblastoma
 

C22.3


Angiosarcoma of liver
 

C22.4


Other sarcomas of liver
 

C22.7


Other specified carcinomas of liver
 

C22.9


Malignant neoplasm of liver, not specified as primary or secondary
 

C23


Malignant neoplasm of gallbladder
 

C24.0


Malignant neoplasm of extrahepatic bile duct
 

C24.8


Malignant neoplasm of overlapping sites of biliary tract
 

C24.9


Malignant neoplasm of biliary tract, unspecified
 

C25.0


Malignant neoplasm of head of pancreas
 

C25.1


Malignant neoplasm of body of pancreas
 

C25.2


Malignant neoplasm of tail of pancreas
 

C25.3


Malignant neoplasm of pancreatic duct
 

C25.4


Malignant neoplasm of endocrine pancreas
 

C25.7


Malignant neoplasm of other parts of pancreas
 

C25.8


Malignant neoplasm of overlapping sites of pancreas
 

C25.9


Malignant neoplasm of pancreas, unspecified
 

C26.0


Malignant neoplasm of intestinal tract, part unspecified
 

C26.1


Malignant neoplasm of spleen
 

C26.9


Malignant neoplasm of ill-defined sites within the digestive system
 

C33


Malignant neoplasm of trachea
 

C34.01


Malignant neoplasm of right main bronchus
 

C34.02


Malignant neoplasm of left main bronchus
 

C34.11


Malignant neoplasm of upper lobe, right bronchus or lung
 

C34.12


Malignant neoplasm of upper lobe, left bronchus or lung
 

C34.2


Malignant neoplasm of middle lobe, bronchus or lung
 

C34.31


Malignant neoplasm of lower lobe, right bronchus or lung
 

C34.32


Malignant neoplasm of lower lobe, left bronchus or lung
 

C34.81


Malignant neoplasm of overlapping sites of right bronchus and lung
 

C34.82


Malignant neoplasm of overlapping sites of left bronchus and lung
 

C34.91


Malignant neoplasm of unspecified part of right bronchus or lung
 

C34.92


Malignant neoplasm of unspecified part of left bronchus or lung
 

C38.0


Malignant neoplasm of heart
 

C38.1


Malignant neoplasm of anterior mediastinum
 

C38.2


Malignant neoplasm of posterior mediastinum
 

C38.3


Malignant neoplasm of mediastinum, part unspecified
 

C38.4


Malignant neoplasm of pleura
 

C38.8


Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
 

C39.0


Malignant neoplasm of upper respiratory tract, part unspecified
 

C45.0


Mesothelioma of pleura
 

C45.1


Mesothelioma of peritoneum
 

C45.2


Mesothelioma of pericardium
 

C47.0


Malignant neoplasm of peripheral nerves of head, face and neck
 

C47.3


Malignant neoplasm of peripheral nerves of thorax
 

C47.4


Malignant neoplasm of peripheral nerves of abdomen
 

C48.0


Malignant neoplasm of retroperitoneum
 

C48.1


Malignant neoplasm of specified parts of peritoneum
 

C48.2


Malignant neoplasm of peritoneum, unspecified
 

C48.8


Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
 

C49.3


Malignant neoplasm of connective and soft tissue of thorax
 

C49.4


Malignant neoplasm of connective and soft tissue of abdomen
 

C61.1


Malignant neoplasm of right kidney, except renal pelvis
 

C64.2


Malignant neoplasm of left kidney, except renal pelvis
 

C76.0


Malignant neoplasm of head, face and neck
 

C76.1


Malignant neoplasm of thorax
 

C76.2


Malignant neoplasm of abdomen
 

C77.8


Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
 

C78.01


Secondary malignant neoplasm of right lung
 

C78.02


Secondary malignant neoplasm of left lung
 

C78.1


Secondary malignant neoplasm of mediastinum
 

C78.2


Secondary malignant neoplasm of pleura
 

C78.30


Secondary malignant neoplasm of unspecified respiratory organ
 

C78.39


Secondary malignant neoplasm of other respiratory organs
 

C78.4


Secondary malignant neoplasm of small intestine
 

C78.5


Secondary malignant neoplasm of large intestine and rectum
 

C78.6


Secondary malignant neoplasm of retroperitoneum and peritoneum
 

C78.7


Secondary malignant neoplasm of liver and intrahepatic bile duct
 

C78.80


Secondary malignant neoplasm of unspecified digestive organ
 

C78.89


Secondary malignant neoplasm of other digestive organs
 

C79.10


Secondary malignant neoplasm of unspecified urinary organs
 

C79.11


Secondary malignant neoplasm of bladder
 

C79.19


Secondary malignant neoplasm of other urinary organs
 

C79.31


Secondary malignant neoplasm of brain
 

C79.51


Secondary malignant neoplasm of bone
 

C79.71


Secondary malignant neoplasm of right adrenal gland
 

C79.72


Secondary malignant neoplasm of left adrenal gland
 

C79.89


Secondary malignant neoplasm of other specified sites
 

C79.9


Secondary malignant neoplasm of unspecified site
 

C83.77


Burkitt lymphoma, spleen
 

D00.1

Carcinoma in situ of esophagus
 

D00.2


Carcinoma in situ of stomach
 

D01.0

Carcinoma in situ of colon
 

D01.1


Carcinoma in situ of rectosigmoid junction
 

D01.2


Carcinoma in situ of rectum
 

D01.3


Carcinoma in situ of anus and anal canal
 

D01.40


Carcinoma in situ of unspecified part of intestine
 

D01.49


Carcinoma in situ of other parts of intestine
 

D01.5


Carcinoma in situ of liver, gallbladder and bile ducts
 

D01.7


Carcinoma in situ of other specified digestive organs
 

D01.9


Carcinoma in situ of digestive organ, unspecified
 

D02.1


Carcinoma in situ of trachea
 

D02.21


Carcinoma in situ of right bronchus and lung
 

D02.22


Carcinoma in situ of left bronchus and lung
 

D02.3


Carcinoma in situ of other parts of respiratory system
 

D02.4


Carcinoma in situ of respiratory system, unspecified
 

D12.0


Benign neoplasm of cecum
 

D12.1


Benign neoplasm of appendix
 

D12.2


Benign neoplasm of ascending colon
 

D12.3


Benign neoplasm of transverse colon
 

D12.4


Benign neoplasm of descending colon
 

D12.5


Benign neoplasm of sigmoid colon
 

D12.6


Benign neoplasm of colon, unspecified
 

D12.7


Benign neoplasm of rectosigmoid junction
 

D12.8


Benign neoplasm of rectum
 

D12.9


Benign neoplasm of anus and anal canal
 

D13.0


Benign neoplasm of esophagus
 

D13.1


Benign neoplasm of stomach
 

D13.2


Benign neoplasm of duodenum
 

D13.30


Benign neoplasm of unspecified part of small intestine
 

D13.39


Benign neoplasm of other parts of small intestine
 

D13.4


Benign neoplasm of liver
 

D13.5


Benign neoplasm of extrahepatic bile ducts
 

D13.6


Benign neoplasm of pancreas
 

D13.7


Benign neoplasm of endocrine pancreas
 

D13.9


Benign neoplasm of ill-defined sites within the digestive system, (Delete ICD-10 CM Effective Date 09/30/2023)
 

D13.91


Familial adenomatous polyposis, (Effective Date  ICD-10 CM 10/01/2023)
 

D13.99


Benign neoplasm of ill-defined sites within the digestive system, (Effective Date  ICD-10 CM 10/01/2023)
 

D14.1


Benign neoplasm of larynx
 

D14.2


Benign neoplasm of trachea
 

D14.31


Benign neoplasm of right bronchus and lung
 

D14.32


Benign neoplasm of left bronchus and lung
 

D15.1


Benign neoplasm of heart
 

D15.7


Benign neoplasm of other specified intrathoracic organs
 

D17.4


Benign lipomatous neoplasm of intrathoracic organs
 

D17.5


Benign lipomatous neoplasm of intra-abdominal organs
 

D17.79


Benign lipomatous neoplasm of other sites
 

D17.9


Benign lipomatous neoplasm, unspecified
 

D19.0


Benign neoplasm of mesothelial tissue of pleura
 

D19.7


Benign neoplasm of mesothelial tissue of other sites
 

D19.9


Benign neoplasm of mesothelial tissue, unspecified
 

D20.0


Benign neoplasm of soft tissue of retroperitoneum
 

D20.1


Benign neoplasm of soft tissue of peritoneum
 

D36.7


Benign neoplasm of other specified sites
 

D36.9


Benign neoplasm, unspecified site
 

D37.1


Neoplasm of uncertain behavior of stomach
 

D37.2


Neoplasm of uncertain behavior of small intestine
 

D37.3


Neoplasm of uncertain behavior of appendix
 

D37.4


Neoplasm of uncertain behavior of colon
 

D37.5


Neoplasm of uncertain behavior of rectum
 

D37.6


Neoplasm of uncertain behavior of liver, gallbladder and bile ducts
 

D37.8


Neoplasm of uncertain behavior of other specified digestive organs
 

D37.9


Neoplasm of uncertain behavior of digestive organ, unspecified
 

D38.0


Neoplasm of uncertain behavior of larynx
 

D38.1


Neoplasm of uncertain behavior of trachea, bronchus and lung
 

D38.2


Neoplasm of uncertain behavior of pleura
 

D38.3


Neoplasm of uncertain behavior of mediastinum
 

D38.4


Neoplasm of uncertain behavior of thymus
 

D48.3


Neoplasm of uncertain behavior of retroperitoneum
 

D48.4

Neoplasm of uncertain behavior of peritoneum
 

K25.0


Acute gastric ulcer with hemorrhage
 

K25.1


Acute gastric ulcer with perforation
 

K25.2


Acute gastric ulcer with both hemorrhage and perforation
 

K25.3


Acute gastric ulcer without hemorrhage or perforation
 

K25.4


Chronic or unspecified gastric ulcer with hemorrhage
 

K25.5


Chronic or unspecified gastric ulcer with perforation
 

K25.6


Chronic or unspecified gastric ulcer with both hemorrhage and perforation
 

K25.7


Chronic gastric ulcer without hemorrhage or perforation
 

K26.0


Acute duodenal ulcer with hemorrhage
 

K26.1


Acute duodenal ulcer with perforation
 

K26.2


Acute duodenal ulcer with both hemorrhage and perforation
 

K26.3


Acute duodenal ulcer without hemorrhage or perforation
 

K26.4


Chronic or unspecified duodenal ulcer with hemorrhage
 

K26.5


Chronic or unspecified duodenal ulcer with perforation
 

K26.6


Chronic or unspecified duodenal ulcer with both hemorrhage and perforation
 

K26.7


Chronic duodenal ulcer without hemorrhage or perforation
 

K26.9


Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
 

K29.01


Acute gastritis with bleeding
 

K29.21


Alcoholic gastritis with bleeding
 

K29.31


Chronic superficial gastritis with bleeding
 

K29.41


Chronic atrophic gastritis with bleeding
 

K29.51


Unspecified chronic gastritis with bleeding
 

K29.61


Other gastritis with bleeding
 

K29.71


Gastritis, unspecified, with bleeding
 

K29.81


Duodenitis with bleeding
 

K30


Functional dyspepsia
 

K31.1


Adult hypertrophic pyloric stenosis
 

K31.2


Hourglass stricture and stenosis of stomach
 

K31.3


Pylorospasm, not elsewhere classified
 

K31.5

Obstruction of duodenum
 

K31.6


Fistula of stomach and duodenum
 

K.31.7


Polyp of stomach and duodenum
 

K31.811


Angiodysplasia of stomach and duodenum with bleeding
 

K31.819


Angiodysplasia of stomach and duodenum without bleeding
 

K31.82


Dieulafoy lesion (hemorrhagic) of stomach and duodenum
 

K31.83


Achlorhydria
 

K31.84


Gastroparesis
 

K31.89


Other diseases of stomach and duodenum
 

K31.9


Disease of stomach and duodenum, unspecified
 

K59.4


Anal spasm
 

K60.0


Acute anal fissure
 

K60.1


Chronic anal fissure
 

K60.2


Anal fissure, unspecified
 

K61.0


Anal abscess
 

K61.1


Rectal abscess
 

K62.0


Anal polyp
 

K62.1


Rectal polyp
 

K62.2


Anal prolapse
 

K62.3


Rectal prolapse
 

K62.4


Stenosis of anus and rectum
 

K62.5


Hemorrhage of anus and rectum
 

K62.6


Ulcer of anus and rectum
 

K62.7


Radiation proctitis
 

K62.81


Anal sphincter tear (healed) (nontraumatic) (old)
 

K62.82


Dysplasia of anus
 

K62.89


Other specified diseases of anus and rectum
 

K62.9


Disease of anus and rectum, unspecified
 

K63.5


Polyp of colon
 

K80.20


Calculus of gallbladder without cholecystitis without obstruction
 

K80.31


Calculus of bile duct with cholangitis, unspecified, with obstruction
 

K80.33


Calculus of bile duct with acute cholangitis with obstruction
 

K80.35


Calculus of bile duct with chronic cholangitis with obstruction
 

K80.37


Calculus of bile duct with acute and chronic cholangitis with obstruction
 

K80.51


Calculus of bile duct without cholangitis or cholecystitis with obstruction
 

K80.80


Other cholelithiasis without obstruction
 

K80.81


Other cholelithiasis with obstruction
 

K82.8


Other specified diseases of gallbladder
 

K82.9


Disease of gallbladder, unspecified
 

K83.1


Obstruction of bile duct
 

K83.8


Other specified diseases of biliary tract
 

K83.9


Disease of biliary tract, unspecified
 

K86.2


Cyst of pancreas
 

K86.3


Pseudocyst of pancreas
 

K86.8


Other specified diseases of pancreas
 

K86.9


Disease of pancreas, unspecified
 

K94.2


Gastrostomy hemorrhage
 

K94.22


Gastrostomy infection
 

R19.00


Intra-abdominal and pelvic swelling, mass and lump, unspecified site
 

R19.01


Right upper quadrant abdominal swelling, mass and lump
 

R19.02


Left upper quadrant abdominal swelling, mass and lump
 

R19.03


Right lower quadrant abdominal swelling, mass and lump
 

R19.04


Left lower quadrant abdominal swelling, mass and lump
 

R19.06


Epigastric swelling, mass or lump
 

R19.07


Generalized intra-abdominal and pelvic swelling, mass and lump
 

R19.09


Other intra-abdominal and pelvic swelling, mass and lump
 

R59.0


Localized enlarged lymph nodes
 

R59.1


Generalized enlarged lymph nodes
 

R59.9


Enlarged lymph nodes, unspecified
 

R68.19


Other nonspecific symptoms peculiar to infancy
 

R93.3


Abnormal findings on diagnostic imaging of other parts of digestive tract

ICD-10 CM

(effective 10/01/2016)

K85.00


Idiopathic acute pancreatitis without necrosis or infection
 

K85.01


Idiopathic acute pancreatitis with uninfected necrosis
 

K85.02


Idiopathic acute pancreatitis with infected necrosis
 

K85.10


Biliary acute pancreatitis without necrosis or infection
 

K85.11


Biliary acute pancreatitis with uninfected necrosis
 

K85.12


Biliary acute pancreatitis with infected necrosis
 

K85.20


Alcohol induced acute pancreatitis without necrosis or infection
 

K85.21


Alcohol induced acute pancreatitis with uninfected necrosis
 

K85.22


Alcohol induced acute pancreatitis with infected necrosis
 

K85.30


Drug induced acute pancreatitis without necrosis or infection
 

K85.32


Drug induced acute pancreatitis with infected necrosis
 

K85.81


Other acute pancreatitis with uninfected necrosis
 

K85.82


Other acute pancreatitis with infected necrosis
 

K85.90


Acute pancreatitis without necrosis or infection, unspecified
 

K85.91


Acute pancreatitis with uninfected necrosis, unspecified
 

K85.92


Acute pancreatitis with infected necrosis, unspecified
 

K86.81


Exocrine pancreatic insufficiency
 

K86.89

K86.89
Other specified diseases of pancreas

Appplicable Modifiers

N/A

Policy History

Date Action Description
08/23/2023 Update on ICD10 codes Add ICD-10 CM (D13.91, D13.99 effective date 10/01/2023), Delete (ICD-10 CM D13.9  effective date 09/30/2023)
01/15/2020 Policy Archived No change in policy statement
09/21/2018 Policy reviewed  
09/19/2016 Policy reviewed  
05/10/2016 Policy reviewed  
10/01/2013 Policy reviewed ICD 10
08/07/2013 Policy reviewed ICD 10
02/27/2013 Policy reviewed  
10/25/2011 Policy reviewed ICD 10
05/20/2009 Policy reviewed ICES
04/09/2008 Policy reviewed  
10/26/2006 Policy created New policy