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Date Printed: August 21, 2017: 07:34 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-46000-01

Original Effective Date: 05/15/12

Reviewed: 03/27/14

Revised: 10/01/16

Subject: High Resolution Anoscopy

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

High resolution anoscopy (HRA) is a procedure which allows for examination and evaluation of the anal canal using a high resolution magnifying instrument (10 - 40x magnification), a colposcope. The anal canal is examined following the application of a mild acidic liquid to the anal canal that aides in the identification of abnormal tissue such as anal dysplasia. If suspicious lesions are found, biopsies are obtained for microscopic examination. HRA is performed in the office and generally lasts approximately fifteen minutes.

POSITION STATEMENT:

High resolution anoscopy meets the definition of medical necessity when used in the diagnosis of a suspicious anal lesion in individuals with abnormal anal physical findings such as, but not limited to the following:

• anogenital warts;

• hypo-pigmented or hyper-pigmented anal plaques/lesions;

• anal lesions that bleed; OR

• any other anal lesion of uncertain etiology.

High resolution anoscopy is considered experimental or investigational when used as a screening test for anal dysplasia and anal cancer. The published clinical literature does not document evidence demonstrating that the use of HRA as a screening tool to identify suspicious anal lesions improves health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

46601

Anoscopy; diagnostic, with high-resolution magnification (HRA) (e.g., colposcope, operating microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when performed

46607

Anoscopy; with high-resolution magnification (HRA) (e.g., colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple

Note: 46601 and 46607 should not be reported with the operating microscope code 69990.

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician history and physical, treatment plan, treatment notes including documentation of symptoms, behavior or pharmacologic interventions, and prior test stimulation (if applicable).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Physician Initial Assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note or treatment notes

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Pathology Study Report

27898-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following Local Coverage Determination (LCD) located at www.fcso.com was reviewed on the last guideline reviewed date: Noncovered Services (L29288)

DEFINITIONS:

Anoscope: a short speculum or endoscope used for direct visual examination of the anal canal.

Colonoscope: a long, thin, flexible tube with a tiny fiber-optic video camera and light at the end of it. The colonoscope is able to bend and flex, and by adjusting the various controls of the colonoscope, the gastroenterologist can carefully maneuver the colonoscope in any direction to investigate the interior of the colon. The colonoscope produces a high quality picture displayed on a monitor, providing a clear, detailed view of the colon.

Dysplasia: abnormal development or growth of tissues, organs, or cells.

RELATED GUIDELINES:

None applicable.

OTHER:

None.

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ). Healthcare Horizon Scanning System AHRQ – Potential High-Impact Interventions Report. Priority Area 09: Infectious Disease Including HIV/AIDS. June 2013.
  2. American Cancer Society. Detailed Guide: Anal Cancer What Is Anal Cancer? Accessed 03/14/13.
  3. American Gastroenterological Association. Society opinion letter. Mark H DeLegge MD, et al. AGA Institute Clinical Practice and Quality Management Committee (2010).
  4. American Society for Colposcopy and Cervical Pathology. Practice Management, Anus. Accessed 03/06/13.
  5. American Society of Colon & Rectal Surgeons. Practice Parameters for Anal Squamous Neoplasms. Steele SR, Varma MG, Melton GB, Ross HM, Rafferty JF, Buie WD on behalf of the Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Diseases of the Colon & Rectum Volume55: 7 (2012).
  6. Berry JM, Palefsky JM, Jay N, Cheng SC, Darragh TM, Chin-Hong PV. Performance characteristics of anal cytology and human papillomavirus testing in patients with high-resolution anoscopy-guided biopsy of high-grade anal intraepithelial neoplasia. Dis Colon Rectum. 2009 Feb;52(2):239-47.
  7. Centers for Disease Control and Prevention (CDC). Treatment Guidelines in HIV Infected Adults and Adolescents (2009).
  8. Echenique I, Phillips BR. Anal Warts and Anal Intradermal Neoplasia. Clin Colon Rectal Surg 2011;24:31–38.
  9. First Coast Service Options, Florida Local Coverage Determination (LCD) Noncovered Services (L29288) (01/29/12).
  10. Gimenez F, Costa-e-Silva IT, Daumas A, Ara├║jo J, Medeiros SG, Ferreira L. The value of high-resolution anoscopy in the diagnosis of anal cancer precursor lesions in HIV-positive patients. Arq Gastroenterol. 2011 Jun;48(2):136-45.
  11. Kaplan JE, Benson C, Holmes KH, et al, Centers for Disease Control and Prevention (CDC), National Institutes of Health, HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2009;58(RR-4):1-207.
  12. National Cancer Institute website. Anal Cancer Screening Study (accessed 03/18/13).
  13. National Comprehensive Cancer Network Guidelines Version 2.2013 Anal Carcinoma.
  14. National Guideline Clearinghouse. New York State Department of Health. Primary care approach to the HIV-infected patient. New York (NY): New York State Department of Health; 2011 Apr. 31.
  15. Pineda CE, Berry JM, Welton ML. High resolution anoscopy and targeted treatment of high-grade squamous intraepithelial lesions. Dis Colon Rectum. 2006 Jan;49(1):126.
  16. Weis SE, Vecino I, Pogoda JM, Susa JS, Nevoit J, Radaford D, McNeely P, Colquitt CA, Adams E. Prevalence of anal intraepithelial neoplasia defined by anal cytology screening and high-resolution anoscopy in a primary care population of HIV-infected men and women. Dis Colon Rectum. 2011 Apr;54(4):433-41.
  17. Wilkin TJ. Screening for anal cancer: Who, when, and how. Medscape HIV/AIDS. New York, NY: Medscape; April 22, 2010. Accessed 04/18/12.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/27/14.

GUIDELINE UPDATE INFORMATION:

05/15/12

New Medical Coverage Guideline.

05/15/13

Scheduled review; position statement unchanged, Program Exceptions section updated, references updated.

04/15/14

Annual review; position statement unchanged; references updated.

01/01/15

Annual coding update: removed 0226T and 0227T; added 46601 and 46607.

11/01/15

Revision: ICD-9 Codes deleted.

01/01/16

Annual HCPCS/CPT update; codes G6027 and G6028 deleted.

10/01/16

Revision; coding section updated; formatting changes.

Date Printed: August 21, 2017: 07:34 PM