Page 264 - Medicare Benefit Policy Manual

280.2.3 - Determining Whether or Not the Beneficiary is at High Risk
for Developing Colorectal Cancer
(Rev. 194, Issued: 09-03-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)

A. Characteristics of the High Risk Individual

An individual at high risk for developing colorectal cancer has one or more of the
following:

A close relative (sibling, parent, or child) who has had colorectal cancer or an
adenomatous polyp;
A family history of familial adenomatous polyposis;
A family history of hereditary nonpolyposis colorectal cancer;
A personal history of colorectal cancer;
A personal history of adenomatous polyps;
Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis.

B. Partial List of ICD-9-CM Codes Indicating High Risk (for Services before
Implementation of ICD-10)

Listed below are some examples of diagnoses that meet the high risk criteria for
colorectal cancer. This is not an all-inclusive list. There may be more instances of
conditions which may be coded and could be at the medical directors’ discretion.

• Personal History

o V10.05 - Personal history of malignant neoplasm of large intestine
o V10.06 - Personal history of malignant neoplasm of rectum, rectosigmoid
junction, and anus

• Chronic Digestive Disease Condition

o 555.0 - Regional enteritis of small intestine
o 555.1 - Regional enteritis of large intestine
o 555.2 - Regional enteritis of small intestine with large intestine
o 555.9 - Regional enteritis of unspecified site
o 556.0 - Ulcerative (chronic) enterocolitis
o 556.1 - Ulcerative (chronic) ileocolitis
o 556.2 - Ulcerative (chronic) proctitis
o 556.3 - Ulcerative (chronic) proctosigmoiditis
o 556.8 - Other ulcerative colitis
o 556.9 - Ulcerative colitis, unspecified (nonspecific PDX on the MCE)

• Inflammatory Bowel