LCD Reference Article Billing and Coding Article

Billing and Coding: High Sensitivity C-Reactive Protein (hsCRP)

A57803

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
First Coast Service Options, Inc.	A and B MAC	09102 - MAC B	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09202 - MAC B	J - N	Puerto Rico
First Coast Service Options, Inc.	A and B MAC	09302 - MAC B	J - N	Virgin Islands

Article Information

General Information

Article ID
A57803

Article Title
Billing and Coding: High Sensitivity C-Reactive Protein (hsCRP)

Article Type
Billing and Coding

Original Effective Date
10/03/2018

Revision Effective Date
N/A

Revision Ending Date
N/A

Retirement Date
N/A

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33908 High Sensitivity C-Reactive Protein (hsCRP) provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

Refer to the LCD for reasonable and necessary requirements and limitations.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.

Coding Guidelines

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Medical record documentation maintained by the ordering/referring physician/qualified nonphysician practitioner must indicate the medical necessity for performing the test and the test results. In addition, if the service exceeds the frequency parameter listed in the LCD, documentation of medical necessity must be submitted upon request.
If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain a copy of test results, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the test. The clinical indication/medical necessity for the test must be indicated in the order for the test.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Compliance with the provisions in LCD L33908, High Sensitivity C-Reactive Protein (hsCRP) may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

Code	Description
999x	Not Applicable

Revenue Codes

Code	Description
99999	Not Applicable

CPT/HCPCS Codes

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Group 1

(1 Code)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
86141	C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP)

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(10 Codes)

Group 1 Paragraph

The following ICD-10-CM codes support medical necessity and provide limited coverage for CPT code: 86141

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Group 1 Codes

Code	Description
E78.00	Pure hypercholesterolemia, unspecified
E78.01	Familial hypercholesterolemia
E78.1	Pure hyperglyceridemia
E78.2	Mixed hyperlipidemia
E78.3	Hyperchylomicronemia
E78.49	Other hyperlipidemia
E78.5	Hyperlipidemia, unspecified
I25.10	Atherosclerotic heart disease of native coronary artery without angina pectoris
Z74.09*	Other reduced mobility
Z78.9*	Other specified health status

Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Use ICD-10-CM code Z74.09 or Z78.9 for patients at intermediate risk for CAD who do not have elevated lipids (i.e., do not meet criteria to use ICD-10-CM codes E78.00-E78.49).

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

(1 Code)

Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes

Code	Description
XX000	Not Applicable

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code	Description
999x	Not Applicable

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code	Description
99999	Not Applicable

Other Coding Information

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

N/A

Associated Documents

Related Local Coverage Documents
LCDs
L33908 - High Sensitivity C-Reactive Protein (hsCRP)

Updated On	Effective Dates	Status
11/22/2019	10/03/2018 - N/A	Currently in Effect	You are here

Keywords

N/A

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Billing and Coding: High Sensitivity C-Reactive Protein (hsCRP)

Document Note

Note History

Contractor Information

Article Information

General Information

CMS National Coverage Policy

Article Guidance

Response To Comments

Coding Information

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Group 1

CPT/HCPCS Modifiers

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

ICD-10-PCS Codes

Group 1

Additional ICD-10 Information

Bill Type Codes

Revenue Codes

Other Coding Information

Group 1

Coding Table Information

Revision History Information

Associated Documents

Keywords

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