CAM 70142

Endoscopic Laser for Gastrointestinal Bleeding

Category:Surgery   Last Reviewed:June 2018
Department(s):Medical Affairs   Next Review:June 2999
Original Date:March 1996    

Description:
The laser beam is directed to the specific site of gastrointestinal bleeding via a fiberglass fiber inserted through a flexible endoscope. The laser then converts light to heat energy to coagulate bleeding sites within the gastrointestinal tract.


Policy:
The use of an endoscopic laser is considered MEDICALLY NECESSARY for control of persistent and severe bleeding of gastrointestinal lesions, including angiodysplasia.

Coding Section

Codes Number Description
CPT 43255 Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method
  45382 Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding, any method
ICD-9 Procedure 44.43 Endoscopic control of gastric or duodenal bleeding
  45.43 Endoscopic destruction of other lesion of tissue of large intestine
ICD-9 Diagnosis 531.00-531.01

Acute gastric ulcer with hemorrhage

  532.00-532.01 Acute duodenal ulcer with hemorrhage
  532.40-532.41 Chronic gastric ulcer with hemorrhage
  533.00-533.01 Acute peptic ulcer with hemorrhage
  533.40-533.41 Chronic peptic ulcer with hemorrhage
  534.00-534.01 Acute gastrojejunal ulcer with hemorrhage
  534.40-534.41 Chronic gastrojejunal ulcer with hemorrhage
  535.0-535.5 Types of gastritis code range. This code range requires the 5th digit of (1) to identify “with hemorrhage”
  535.61 Duodenitis with hemorrhage
  537.83 Angiodysplasia of stomach and duodenum with hemorrhage
  569.82 Ulceration of intestine
  569.85 Angiodysplasia of intestine with hemorrhage
  578.9 Hemorrhage of gastrointestinal tract, unspecified
    Note: Codes 569.82 & 578.9 should always be used together to identify bleeding intestinal ulcer (578.9 would not be used alone because it is unspecified, and there is no intestinal ulcer code that specifies with hemorrhage)
HCPCS No code  
ICD-10-CM (effective 10/01/15) 0W3P8ZZ Control Bleeding in Gastrointestinal Tract, Via Natural or Artificial Opening Endoscopic
  0D5E8ZZ Destruction of Large Intestine, Percutaneous Endoscopic Approach
ICD-10-PCS (effective 10/01/15) K250 Acute gastric ulcer with hemorrhage
  K260 Acute duodenal ulcer with hemorrhage
  K264 Chronic or unspecified duodenal ulcer with hemorrhage
  K270 Acute peptic ulcer, site unspecified, with hemorrhage
  K274 Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage
  K280 Acute gastrojejunal ulcer with hemorrhage
  K284 Chronic or unspecified gastrojejunal ulcer with hemorrhage
  K2900 Acute gastritis without bleeding
  K2901 Acute gastritis with bleeding
  K2920 Alcoholic gastritis without bleeding
  K2921 Alcoholic gastritis with bleeding
  K2940 Chronic atrophic gastritis without bleeding
  K2941 Chronic atrophic gastritis with bleeding
  K2950 Unspecified chronic gastritis without bleeding
  K2951 Unspecified chronic gastritis with bleeding
  K2960 Other gastritis without bleeding
  K2961 Other gastritis with bleeding
  K2970 Gastritis, unspecified, without bleeding
  K2990 Gastroduodenitis, unspecified, without bleeding
  K2981 Duodenitis with bleeding
  K31811 Angiodysplasia of stomach and duodenum with bleeding
  K633 Ulcer of intestine
  K5521 Angiodysplasia of colon with hemorrhage
  K922 Gastrointestinal hemorrhage, unspecified
Type of Service Surgery  
Place of Service Inpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

07/03/2018 

Annual review, no change to policy intent. 

06/22/2017 

Annual review, no changes to policy intent 

06/06/2016 

Annual review, no changes to policy intent. 

06/02/2015 

Annual review, no changes to policy intent. Added coding. 

06/03/2014

Annual review, no changes made


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