Local Coverage Determination (LCD)

Sedimentation Rate, Erythrocyte

L34021

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34021
Original ICD-9 LCD ID
Not Applicable
LCD Title
Sedimentation Rate, Erythrocyte
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 01/08/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Sedimentation Rate, Erythrocyte. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Sedimentation Rate, Erythrocyte and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

Internet Only Manual (IOM) Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD 

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Federal Register References:

  • Code of Federal Regulations (CFR), Title 42, Volume 2, Chapter IV, Part 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

History/Background and/or General Information

The erythrocyte sedimentation rate (ESR) is a sensitive but nonspecific test that is frequently the earliest indicator of disease when other chemical or physical signs are normal. It is most often used as a gauge for determining the progress and detection of an inflammatory disorder caused by infection, autoimmune mechanisms, or connective tissue disease.

Covered Indications

An ESR will be considered medically reasonable and necessary for one of the following conditions:

  • Aiding in the diagnosis of temporal arteritis (giant cell arteritis) and polymyalgia rheumatic
  • Monitoring disease activity in temporal arteritis and polymyalgia rheumatica for the principal indication of adjusting the dosage of corticosteroids
  • Monitoring patients with treated Hodgkin’s disease
  • Monitoring patients with autoimmune diseases, inflammatory disorders caused by infection, or connective tissue diseases

An ESR should be used selectively in patients with symptoms that are not explained by results of a careful history and physical examination. Rapid screen for elevated protein or globulin level in serum ESR may be used with or replaced by C-Reactive protein in evaluation of unexplained inflammatory states .

Limitations

This service is not medically necessary for screening purposes.

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

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

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Sedimentation Rate, Erythrocyte (A57657) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Sedimentation Rate, Erythrocyte (A57657) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

Sources of Information

First Coast Service Options Inc. reference LCD number(s) – L29016, L29277, L29392 Clinical Laboratory Tests, Values and Implications; Springhouse Corporation

Epperly, T.D., Moore, K.E., Harrover, J.D. (2000). Polymyalgia rheumatica and temporal arteritis. American Family Physician 62(4). Retrieved September 4,2002 from MD Consult database 11490718.

Taber's Cyclopedic Medical Dictionary

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
01/08/2019 R6

Revision Number: 5
Publication: November 2019 Connection
LCR A/B2019-075

Explanation of Revision: Based on Change Request (CR) 10901, the LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions (“Bill Type Codes,” “Revenue Codes,” “CPT/HCPCS Codes,” “ICD-10 Codes that Support Medical Necessity,” “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. During the process of moving the ICD-10-CM diagnosis codes to the billing and coding article, the ICD-10-CM diagnosis code ranges were broken out and listed individually. In addition, the Social Security Act, Code of Federal Regulations, and IOM reference sections were updated. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.

  • Other (Revision based on CR10901)
10/01/2018 R5

Revision Number: 4
Publication: September 2018 Connection
LCR A/B2018-074

Explanation of revision: Based on CR 10847 (Annual 2019 ICD-10-CM Update), the LCD was revised. Deleted ICD-10-CM diagnosis code M79.1. Added ICD-10-CM diagnosis code range M79.11-M79.18. The effective date of this revision is based on date of service.

10/01/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.

  • Revisions Due To ICD-10-CM Code Changes
02/08/2018 R4

Revision Number: 2

Publication: February 2018 Connection

LCR A/B2018-012

Explanation of revision:  This LCD has been revised to include an explanation that all the codes within the asterisked range from the first code to the last code apply for ICD-10-CM code ranges in the “ICD-10 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision is based on process date.

02/08/2018:  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Public Education/Guidance
10/01/2017 R3

 

Revision Number:  3

 

Based on CR 10153 (2018 ICD-10 Update) LCD was evaluated and impacts identified.  The new ICD-10-CM changes are effective for dates of service on or after 10/01/2017.

 

  • Revisions Due To ICD-10-CM Code Changes
05/12/2017 R2

Revision Number: 1 Publication: June 2017 Connection LCR A/B2017-023


Explanation of Revision: Based on CR 8776, the following verbiage was removed from the “CPT/HCPCS Codes” section of the LCD: “Per CR 8572, beginning in CY 2014, payment for most laboratory tests (except for molecular pathology tests) will be packaged under the OPPS, therefore the clinical laboratory tests listed below, for TOB 13X (outpatient hospital), are packaged in this setting.” The effective date of this revision is for claims processed on or after 05/12/2017, for dates of service on or after 01/01/2014.

  • Provider Education/Guidance
10/01/2015 R1 03/04/15 - The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Provider Education/Guidance
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A57657 - Billing and Coding: Sedimentation Rate, Erythrocyte
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/21/2019 01/08/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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