CMS Pub. 100-04, ch. 18, § 60.3

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 adenomatous polyps.

• A personal history of colorectal cancer; or

• Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis.

B. Partial List of ICD-10-CM Codes Indicating High Risk

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 considered high risk at the medical directors’ discretion.

Partial List of diagnosis codes indicating high risk: only applicable to G0105 and G0120 (high risk

colorectal cancer screening)

C18.0 Malignant neoplasm of cecum

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

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

C49.A Gastrointestinal stromal tumor of small intestine

C49.A Gastrointestinal stromal tumor of large intestine

C49.A5 Gastrointestinal stromal tumor of rectum

C78.5 Secondary malignant neoplasm of large intestine and rectum

C7A.02 Malignant carcinoid tumor of the cecum

C7A.022 Malignant carcinoid tumor of the ascending colon

C7A.023 Malignant carcinoid tumor of the transverse colon

C7A.024 Malignant carcinoid tumor of the descending colon

C7A.025 Malignant carcinoid tumor of the sigmoid colon

C7A.026 Malignant carcinoid tumor of the rectum

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

D12.0 Benign neoplasm of cecum

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

D12.7 Benign neoplasm of rectosigmoid junction

D12.8 Benign neoplasm of rectum

D12.9 Benign neoplasm of anus and anal canal

D37.4 Neoplasm of uncertain behavior of colon

D37.5 Neoplasm of uncertain behavior of rectum

D37.9 Neoplasm of uncertain behavior of digestive organ, unspecified

D3A.021 Benign carcinoid tumor of the cecum

D3A.022 Benign carcinoid tumor of the ascending colon

D3A.023 Benign carcinoid tumor of the transverse colon

D3A.024 Benign carcinoid tumor of the descending colon

D3A.025 Benign carcinoid tumor of the sigmoid colon

D3A.026 Benign carcinoid tumor of the rectum

D3A.029 Benign carcinoid tumor of the large intestine, unspecified portion

K50.00 Crohn's disease of small intestine without complications

K50.011 Crohn's disease of small intestine with rectal bleeding

K50.012 Crohn's disease of small intestine with intestinal obstruction

K50.013 Crohn's disease of small intestine with fistula

K50.014 Crohn's disease of small intestine with abscess

K50.018 Crohn's disease of small intestine with other complication

K50.019 Crohn's disease of small intestine with unspecified complications

K50.10 Crohn's disease of large intestine without complications

K50.111 Crohn's disease of large intestine with rectal bleeding

K50.112 Crohn's disease of large intestine with intestinal obstruction

K50.113 Crohn's disease of large intestine with fistula

K50.114 Crohn's disease of large intestine with abscess

K50.118 Crohn's disease of large intestine with other complication

K50.119 Crohn's disease of large intestine with unspecified complications

K50.80 Crohn's disease of both small and large intestine without complications

K50.811 Crohn's disease of both small and large intestine with rectal bleeding

K50.812 Crohn's disease of both small and large intestine with intestinal

obstruction

K50.813 Crohn's disease of both small and large intestine with fistula

K50.814 Crohn's disease of both small and large intestine with abscess

K50.818 Crohn's disease of both small and large intestine with other complication

K50.819 Crohn's disease of both small and large intestine with unspecified complications

K50.90 Crohn's disease, unspecified, without complications

K50.911 Crohn's disease, unspecified, with rectal bleeding

K50.912 Crohn's disease, unspecified, with intestinal obstruction

K50.913 Crohn's disease, unspecified, with fistula

K50.914 Crohn's disease, unspecified, with abscess

K50.918 Crohn's disease, unspecified, with other complication

K50.919 Crohn's disease, unspecified, with unspecified complications

K51.00 Ulcerative (chronic) pancolitis without complications

K51.011 Ulcerative (chronic) pancolitis with rectal bleeding

K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction

K51.013 Ulcerative (chronic) pancolitis with fistula

K51.014 Ulcerative (chronic) pancolitis with abscess

K51.018 Ulcerative (chronic) pancolitis with other complication

K51.019 Ulcerative (chronic) pancolitis with unspecified complications

K51.20 Ulcerative (chronic) proctitis without complications

K51.211 Ulcerative (chronic) proctitis with rectal bleeding

K51.212 Ulcerative (chronic) proctitis with intestinal obstruction

K51.213 Ulcerative (chronic) proctitis with fistula

K51.214 Ulcerative (chronic) proctitis with abscess

K51.218 Ulcerative (chronic) proctitis with other complication

K51.219 Ulcerative (chronic) proctitis with unspecified complications

K51.30 Ulcerative (chronic) rectosigmoiditis without complications

K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding

K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction

K51.313 Ulcerative (chronic) rectosigmoiditis with fistula

K51.314 Ulcerative (chronic) rectosigmoiditis with abscess

K51.318 Ulcerative (chronic) rectosigmoiditis with other complication

K51.319 Ulcerative (chronic) rectosigmoiditis with unspecified complications

K51.40 Inflammatory polyps of colon without complications

K51.411 Inflammatory polyps of colon with rectal bleeding

K51.412 Inflammatory polyps of colon with intestinal obstruction

K51.413 Inflammatory polyps of colon with fistula

K51.414 Inflammatory polyps of colon with abscess

K51.418 Inflammatory polyps of colon with other complication

K51.419 Inflammatory polyps of colon with unspecified complications

K51.50 Left sided colitis without complications

K51.511 Left sided colitis with rectal bleeding

K51.512 Left sided colitis with intestinal obstruction

K51.513 Left sided colitis with fistula

K51.514 Left sided colitis with abscess

K51.518 Left sided colitis with other complication

K51.519 Left sided colitis with unspecified complications

K51.80 Other ulcerative colitis without complications

K51.811 Other ulcerative colitis with rectal bleeding

K51.812 Other ulcerative colitis with intestinal obstruction

K51.813 Other ulcerative colitis with fistula

K51.814 Other ulcerative colitis with abscess

K51.818 Other ulcerative colitis with other complication

K51.819 Other ulcerative colitis with unspecified complications

K51.90 Ulcerative colitis, unspecified, without complications

K51.911 Ulcerative colitis, unspecified with rectal bleeding

K51.912 Ulcerative colitis, unspecified with intestinal obstruction

K51.913 Ulcerative colitis, unspecified with fistula

K51.914 Ulcerative colitis, unspecified with abscess

K51.918 Ulcerative colitis, unspecified with other complication

K51.919 Ulcerative colitis, unspecified with unspecified complications

K52.1 Toxic gastroenteritis and colitis

K52.89 Other specified non-infective gastroenteritis and colitis

K52.9 Non-infective gastroenteritis and colitis, unspecified

K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding

K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding

K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding

K57.31 Diverticulosis of large intestine without perforation or abscess with bleeding

K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding

K57.33 Diverticulitis of large intestine without perforation or abscess with bleeding

K57.40 Diverticulitis of both small and large intestine with perforation and abscess

without bleeding

K57.41 Diverticulitis of both small and large intestine with perforation and abscess with

bleeding

K57.50 Diverticulosis of both small and large intestine without perforation or abscess

without bleeding

K57.51 Diverticulosis of both small and large intestine without perforation or abscess

with bleeding

K57.52 Diverticulitis of both small and large intestine without perforation or abscess

without bleeding

K57.53 Diverticulitis of both small and large intestine without perforation or abscess with

bleeding

K57.80 Diverticulitis of intestine, part unspecified, with perforation and abscess without

bleeding

K57.81 Diverticulitis of intestine, part unspecified, with perforation and abscess with

bleeding

K57.90 Diverticulosis of intestine, part unspecified, without perforation or abscess

without bleeding

K57.91 Diverticulosis of intestine, part unspecified, without perforation or abscess with

bleeding

K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without

bleeding

K57.93 Diverticulitis of intestine, part unspecified, without perforation or abscess with

bleeding

K62.0 Anal polyp

K62.1 Rectal polyp

K62.6 Ulcer of anus and rectum

K63.3 Ulcer of intestine

K63.5 Polyp of colon

Z12.10 Encounter for screening for malignant neoplasm of intestinal tract, unspecified

Z12.11 Encounter for screening for malignant neoplasm of colon

Z12.12 Encounter for screening for malignant neoplasm of rectum

Z15.09 Genetic susceptibility to other malignant neoplasm

Z80.0 Family history of malignant neoplasm of digestive organs

Z83.710 Family history of adenomatous and serrated polyps

Z83.711 Family history of hyperplastic colon polyps

Z83.718 Other family history of colon polyps

Z83.719 Family history of colon polyps, unspecified

Z83.72 Family history of familial adenomatous polyposis effective October 1 ,2024

Z85.038 Personal history of other malignant neoplasm of large intestine

Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and

anus

Z86.004 Personal history of in-situ neoplasm of other and unspecified digestive organs

Z86.010 Personal history of colonic polyps end date September 30, 2024

Z86.0100 Personal history of colon polyps, unspecified effective October 1 ,2024

Z86.0101 Personal history of adenomatous and serrated colon polyps effective October 1,

2024

Z86.0102 Personal history of hyperplastic colon polyps effective October 1 ,2024

Z86.0109 Personal history of other colon polyps October 1 ,2024

Applicable to G0464/81528: colorectal cancer screening; stool-based DNA and fecal occult

hemoglobin (e.g., kras, ndrg4 and bmp3), as well as G0327: colorectal cancer screening; blood-based biomarker - only 1 diagnosis required

Z12.12 Encounter for screening for malignant neoplasm of rectum

Z12.11 Encounter for screening for malignant neoplasm of colon