Virtual (CT) Colonoscopy Reimbursement
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This policy governs University Health Alliance reimbursement for CT colonography (virtual colonoscopy), including medical necessity criteria, prior authorization requirements, and coding guidance for providers submitting claims.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Criteria
Medical necessity criteria
Virtual Colonoscopy may be considered medically necessary when criteria in any of the following categories are met and documented in the medical record.
A. Diagnostic when conventional colonoscopy is contraindicated
- Patient had failed colonoscopy due to conditions such as hypotension secondary to the sedation; adhesions from prior surgery; excessive colonic tortuosity.
- Patient has obstructive colorectal cancer.
- Patient is unable to undergo sedation or has a medical condition that limits the safe use of alternative diagnostic modalities (e.g., recent myocardial infarction, recent colonic surgery, bleeding disorders, severe lung and/or heart disease).
B. Colorectal cancer screening for asymptomatic patients
- Endoscopic screening chosen but colonic tortuosity prevented thorough endoscopic colonoscopy.
- Patient is on anticoagulation therapy which cannot be interrupted.
- Patient cannot tolerate the sedation necessary for endoscopic colonoscopy (based on severe underlying medical conditions or past proven intolerance).
C. Follow-up studies
- Follow-up study to evaluate progress after treatment, procedure, intervention or surgery with documentation of a medical reason that clearly indicates why additional imaging is needed for the requested type and area(s).
Appropriate Indications for CT Colonography
Appropriate indications for CT colonography
Appropriate indications for CT colonography (virtual colonoscopy):
Coding Guidance for CT Colonography
| 74262 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed |
| 52 | Used for cases of failed flexible colonoscopy when CT colonography is accomplished within 24 hours. Please submit claim with appropriate CPT code. Also include documentation of failed flexible colonoscopy for verification and to ensure proper processing. |
Prior Authorization and Provider Steps
Prior authorization required; exception for failed flexible colonoscopy
Prior authorization is required for CT colonography except when performed after a failed flexible colonoscopy that is accomplished within 36 hours. In those exception cases submit the claim with the appropriate CPT code using modifier 52 and include documentation of the failed flexible colonoscopy for verification and proper processing.
- Exception applies only when CT colonography is accomplished within 36 hours of the failed flexible colonoscopy.
- Include documentation of the failed flexible colonoscopy when submitting the claim with modifier 52.
How to request prior authorization
Submit prior authorization requests through UHA's online portal.
CT prior authorization and failed colonoscopy exception (modifier 52)
Prior authorization is required for CT colonography except when the exam is performed within 36 hours after a failed flexible colonoscopy; in that situation submit the claim with the appropriate CPT code and modifier 52 and include documentation of the failed colonoscopy.
- Use modifier 52 on the CT colonography CPT code when the study follows a failed flexible colonoscopy within the 36-hour window.
- Attach documentation of the failed flexible colonoscopy to ensure proper claim processing.
Contrast Use for CT Colonography
Contrast use for CT colonography (CPT 74262)
CT colonography may be performed with or without contrast as clinically indicated; CPT 74262 describes CT colonography without contrast and with contrast images if performed.
- Report CPT 74262 for CT colonography; this code covers non-contrast studies and contrast-enhanced images when obtained.
Definitions
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