SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

Palmetto GBA
Contractor Number ^{back to top}
00380
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back to top}

L1287

LCD Title ^{back to top}
Sedimentation Rate, Erythrocyte

Contractor's Determination Number ^{back to top}
98A-0014-L

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS Manual System, Pub 100-08, Medicare Program Integrity, Transmittal 63, dated January 23, 2004, Change Request 3010

Primary Geographic Jurisdiction ^{back to top}
South Carolina

Oversight Region ^{back to top}
Region IV

Original Determination Effective Date ^{back to top}
For services performed on or after 09/21/1998

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 02/05/2009

Revision Ending Date ^{back to top}
09/30/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes settle out of unclotted blood in one hour. This test is based on the fact that inflammatory and necrotic processes cause alteration in blood proteins, causing an aggregation of red blood cells. Heavier red blood cells fall more rapidly when placed in vertical tubes. It is a nonspecific test (not considered diagnostic for any particular organ disease or injury). Erythrocyte sedimentation rate (ESR) is frequently the earliest indicator of disease when other chemical or physical signs are normal. 1. Erythrocyte sedimentation rate is a covered service under the Medicare program when deemed medically necessary. 2.The ESR is a covered service for: a. aiding in the diagnosis of temporal arteritis (giant cell arteritis) and polymyalgia rheumatica b. monitoring disease activity in temporal arteritis and polymyalgia rheumatica for the principle indication of adjusting the dosage of corticosteroids c. monitoring patients with treated Hodgkin’s disease d. monitoring patients with autoimmune diseases, including rheumatoid arthritis e. determining inflammatory, neoplastic, infectious, and necrotic processes

Coding Information

Bill Type Codes: ^{back to top}

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens
18x	Hospital-swing beds
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
71x	Clinic-rural health
72x	Clinic-hospital based or independent renal dialysis facility
73x	Clinic-independent provider based FQHC (eff 10/91)
85x	Special facility or ASC surgery-rural primary care hospital (eff 10/94)

Revenue Codes: ^{back to top}

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

030X	Laboratory-general classification

CPT/HCPCS Codes ^{back to top}

85651	SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED
85652	SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED

ICD-9 Codes that Support Medical Necessity ^{back to top}

038.0	STREPTOCOCCAL SEPTICEMIA
066.40 - 066.49	WEST NILE FEVER, UNSPECIFIED - WEST NILE FEVER WITH OTHER COMPLICATIONS
075	INFECTIOUS MONONUCLEOSIS
079.82	SARS-ASSOCIATED CORONAVIRUS INFECTION
079.83	PARVOVIRUSB19
090.0	EARLY CONGENITAL SYPHILIS SYMPTOMATIC
091.0 - 091.9	GENITAL SYPHILIS (PRIMARY) - UNSPECIFIED SECONDARY SYPHILIS
093.0 - 093.9	ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC - CARDIOVASCULAR SYPHILIS UNSPECIFIED
094.2	SYPHILITIC MENINGITIS
094.81	SYPHILITIC ENCEPHALITIS
099.3	REITER'S DISEASE
136.1	BEHCET'S SYNDROME
136.3	PNEUMOCYSTOSIS
136.9	UNSPECIFIED INFECTIOUS AND PARASITIC DISEASES
200.20 - 200.28	BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.30 - 200.38	MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.40 - 200.48	MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.50 - 200.58	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.60 - 200.68	ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.70 - 200.78	LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
201.00 - 201.28	HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
201.40 - 201.98	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00 - 202.08	NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.70 - 202.78	PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.80 - 202.88	OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
203.00	MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01	MULTIPLE MYELOMA IN REMISSION
203.02	MULTIPLE MYELOMA, IN RELAPSE
203.10	PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.11	PLASMA CELL LEUKEMIA IN REMISSION
203.12	PLASMA CELL LEUKEMIA, IN RELAPSE
203.80	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.81	OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION
203.82	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE
240.0 - 240.9	GOITER SPECIFIED AS SIMPLE - GOITER UNSPECIFIED
241.0 - 241.9	NONTOXIC UNINODULAR GOITER - UNSPECIFIED NONTOXIC NODULAR GOITER
242.00 - 242.91	TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM
245.0 - 245.9	ACUTE THYROIDITIS - THYROIDITIS UNSPECIFIED
246.8	OTHER SPECIFIED DISORDERS OF THYROID
253.0	ACROMEGALY AND GIGANTISM
270.2	OTHER DISTURBANCES OF AROMATIC AMINO-ACID METABOLISM
272.0 - 272.9	PURE HYPERCHOLESTEROLEMIA - UNSPECIFIED DISORDER OF LIPOID METABOLISM
273.1	MONOCLONAL PARAPROTEINEMIA
273.3	MACROGLOBULINEMIA
274.0 - 274.9	GOUTY ARTHROPATHY - GOUT UNSPECIFIED
275.0	DISORDERS OF IRON METABOLISM
279.00 - 279.09	HYPOGAMMAGLOBULINEMIA UNSPECIFIED - OTHER DEFICIENCY OF HUMORAL IMMUNITY
279.4	AUTOIMMUNE DISEASE NOT ELSEWHERE CLASSIFIED
282.60 - 282.69	SICKLE-CELL DISEASE UNSPECIFIED - OTHER SICKLE-CELL DISEASE WITH CRISIS
285.9	ANEMIA UNSPECIFIED
286.0 - 286.9	CONGENITAL FACTOR VIII DISORDER - OTHER AND UNSPECIFIED COAGULATION DEFECTS
287.0	ALLERGIC PURPURA
288.00 - 288.09	NEUTROPENIA, UNSPECIFIED - OTHER NEUTROPENIA
288.3	EOSINOPHILIA
288.4	HEMOPHAGOCYTIC SYNDROMES
288.50 - 288.59	LEUKOCYTOPENIA, UNSPECIFIED - OTHER DECREASED WHITE BLOOD CELL COUNT
288.60 - 288.65	LEUKOCYTOSIS, UNSPECIFIED - BASOPHILIA
288.66	BANDEMIA
288.69	OTHER ELEVATED WHITE BLOOD CELL COUNT
348.30	ENCEPHALOPATHY UNSPECIFIED
348.31	METABOLIC ENCEPHALOPATHY
348.39	OTHER ENCEPHALOPATHY
350.2	ATYPICAL FACE PAIN
354.5	MONONEURITIS MULTIPLEX
362.18	RETINAL VASCULITIS
362.30	RETINAL VASCULAR OCCLUSION UNSPECIFIED
362.31	CENTRAL RETINAL ARTERY OCCLUSION
362.34	TRANSIENT RETINAL ARTERIAL OCCLUSION
363.20	CHORIORETINITIS UNSPECIFIED
364.00 - 364.11	ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED - CHRONIC IRIDOCYCLITIS IN DISEASES CLASSIFIED ELSEWHERE
364.3	UNSPECIFIED IRIDOCYCLITIS
368.11	SUDDEN VISUAL LOSS
368.12	TRANSIENT VISUAL LOSS
369.60	BLINDNESS ONE EYE NOT OTHERWISE SPECIFIED
369.9	UNSPECIFIED VISUAL LOSS
377.39	OTHER OPTIC NEURITIS
377.41	ISCHEMIC OPTIC NEUROPATHY
378.52	THIRD OR OCULOMOTOR NERVE PALSY TOTAL
378.53	FOURTH OR TROCHLEAR NERVE PALSY
378.54	SIXTH OR ABDUCENS NERVE PALSY
379.02	NODULAR EPISCLERITIS
379.03	ANTERIOR SCLERITIS
379.60 - 379.63	INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, UNSPECIFIED - INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 3
390	RHEUMATIC FEVER WITHOUT HEART INVOLVEMENT
391.0 - 391.8	ACUTE RHEUMATIC PERICARDITIS - OTHER ACUTE RHEUMATIC HEART DISEASE
391.9	ACUTE RHEUMATIC HEART DISEASE UNSPECIFIED
410.00 - 410.72	ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE
410.80 - 410.92	ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE
415.12	SEPTIC PULMONARY EMBOLISM
420.0	ACUTE PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE
420.90 - 420.99	ACUTE PERICARDITIS UNSPECIFIED - OTHER ACUTE PERICARDITIS
421.1	ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE
421.9	ACUTE ENDOCARDITIS UNSPECIFIED
422.0	ACUTE MYOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE
422.90 - 422.99	ACUTE MYOCARDITIS UNSPECIFIED - OTHER ACUTE MYOCARDITIS
424.90 - 424.99	ENDOCARDITIS VALVE UNSPECIFIED UNSPECIFIED CAUSE - OTHER ENDOCARDITIS VALVE UNSPECIFIED
425.4	OTHER PRIMARY CARDIOMYOPATHIES
430 - 437.9	SUBARACHNOID HEMORRHAGE - UNSPECIFIED CEREBROVASCULAR DISEASE
443.0	RAYNAUD'S SYNDROME
446.0	POLYARTERITIS NODOSA
446.5	GIANT CELL ARTERITIS
447.6	ARTERITIS UNSPECIFIED
449	SEPTIC ARTERIAL EMBOLISM
486	PNEUMONIA ORGANISM UNSPECIFIED
515	POSTINFLAMMATORY PULMONARY FIBROSIS
518.3	PULMONARY EOSINOPHILIA
518.7	TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)
524.62	TEMPOROMANDIBULAR JOINT DISORDERS ARTHRALGIA OF TEMPOROMANDIBULAR JOINT
526.61 - 526.69	PERFORATION OF ROOT CANAL SPACE - OTHER PERIRADICULAR PATHOLOGY ASSOCIATED WITH PREVIOUS ENDODONTIC TREATMENT
526.9	UNSPECIFIED DISEASE OF THE JAWS
529.6	GLOSSODYNIA
555.0 - 555.9	REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE
556.0 - 556.9	ULCERATIVE (CHRONIC) ENTEROCOLITIS - ULCERATIVE COLITIS UNSPECIFIED
558.1 - 558.9	GASTROENTERITIS AND COLITIS DUE TO RADIATION - OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS
571.42	AUTOIMMUNE HEPATITIS
580.0 - 580.9	ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
581.0 - 581.9	NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
692.9	CONTACT DERMATITIS AND OTHER ECZEMA UNSPECIFIED CAUSE
695.4	LUPUS ERYTHEMATOSUS
696.0	PSORIATIC ARTHROPATHY
698.9	UNSPECIFIED PRURITIC DISORDER
708.9	UNSPECIFIED URTICARIA
710.0 - 710.2	SYSTEMIC LUPUS ERYTHEMATOSUS - SICCA SYNDROME
710.3	DERMATOMYOSITIS
710.4	POLYMYOSITIS
710.5	EOSINOPHILIA MYALGIA SYNDROME
710.8	OTHER SPECIFIED DIFFUSE DISEASES OF CONNECTIVE TISSUE
710.9	UNSPECIFIED DIFFUSE CONNECTIVE TISSUE DISEASE
711.00 - 711.99	PYOGENIC ARTHRITIS SITE UNSPECIFIED - UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING MULTIPLE SITES
712.10 - 712.99	CHONDROCALCINOSIS DUE TO DICALCIUM PHOSPHATE CRYSTALS INVOLVING UNSPECIFIED SITE - UNSPECIFIED CRYSTAL ARTHROPATHY INVOLVING MULTIPLE SITES
713.1	ARTHROPATHY ASSOCIATED WITH GASTROINTESTINAL CONDITIONS OTHER THAN INFECTIONS
713.5	ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS
713.6	ARTHROPATHY ASSOCIATED WITH HYPERSENSITIVITY REACTION
714.0	RHEUMATOID ARTHRITIS
714.1	FELTY'S SYNDROME
714.2	OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT
714.30	CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS
714.31 - 714.33	ACUTE POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS - MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS
714.4	CHRONIC POSTRHEUMATIC ARTHROPATHY
714.81	RHEUMATOID LUNG
714.89	OTHER SPECIFIED INFLAMMATORY POLYARTHROPATHIES
714.9	UNSPECIFIED INFLAMMATORY POLYARTHROPATHY
715.00 - 715.98	OSTEOARTHROSIS GENERALIZED INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING OTHER SPECIFIED SITES
716.01 - 716.58	KASCHIN-BECK DISEASE INVOLVING SHOULDER REGION - UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING OTHER SPECIFIED SITES
716.59	UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING MULTIPLE SITES
716.60 - 716.99	UNSPECIFIED MONOARTHRITIS SITE UNSPECIFIED - UNSPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES
719.01 - 719.39	EFFUSION OF JOINT OF SHOULDER REGION - PALINDROMIC RHEUMATISM INVOLVING MULTIPLE SITES
719.40	PAIN IN JOINT SITE UNSPECIFIED
719.41 - 719.49	PAIN IN JOINT INVOLVING SHOULDER REGION - PAIN IN JOINT INVOLVING MULTIPLE SITES
720.0	ANKYLOSING SPONDYLITIS
720.1	SPINAL ENTHESOPATHY
720.2	SACROILIITIS NOT ELSEWHERE CLASSIFIED
720.81 - 720.89	INFLAMMATORY SPONDYLOPATHIES IN DISEASES CLASSIFIED ELSEWHERE - OTHER INFLAMMATORY SPONDYLOPATHIES
720.9	UNSPECIFIED INFLAMMATORY SPONDYLOPATHY
721.0	CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY
721.2	THORACIC SPONDYLOSIS WITHOUT MYELOPATHY
721.3	LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY
724.2	LUMBAGO
724.5	BACKACHE UNSPECIFIED
725	POLYMYALGIA RHEUMATICA
727.00	SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED
728.9	UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA
729.1	MYALGIA AND MYOSITIS UNSPECIFIED
730.00 - 730.08	ACUTE OSTEOMYELITIS SITE UNSPECIFIED - ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES
730.09	ACUTE OSTEOMYELITIS INVOLVING MULTIPLE SITES
730.10 - 730.18	CHRONIC OSTEOMYELITIS SITE UNSPECIFIED - CHRONIC OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES
730.19	CHRONIC OSTEOMYELITIS INVOLVING MULTIPLE SITES
733.00	OSTEOPOROSIS UNSPECIFIED
733.01	SENILE OSTEOPOROSIS
733.02	IDIOPATHIC OSTEOPOROSIS
733.99	OTHER DISORDERS OF BONE AND CARTILAGE
780.32	COMPLEX FEBRILE CONVULSIONS
780.60	FEVER, UNSPECIFIED
780.61	FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE
780.64	CHILLS (WITHOUT FEVER)
780.65	HYPOTHERMIA NOT ASSOCIATED WITH LOW ENVIRONMENTAL TEMPERATURE
780.96	GENERALIZED PAIN
780.97	ALTERED MENTAL STATUS
784.0	HEADACHE
784.1	THROAT PAIN
786.52	PAINFUL RESPIRATION
787.91	DIARRHEA
790.1	ELEVATED SEDIMENTATION RATE
E933.1	ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
E933.8	OTHER SYSTEMIC AGENTS NOT ELSEWHERE CLASSIFIED CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
E935.6	ANTIRHEUMATICS (ANTIPHLOGISTICS) CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
E947.2	ANTIDOTES AND CHELATING AGENTS NOT ELSEWHERE CLASSIFIED CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
V10.72	PERSONAL HISTORY OF HODGKIN'S DISEASE

Diagnoses that Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

N/A

General Information

Documentation Requirements ^{back to top}

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.

Appendices ^{back to top}

N/A

Utilization Guidelines ^{back to top}

ICD-9-CM code 784.0 was added to the ICD-9-CM CODES THAT SUPPORT MEDICAL NECESSITY section of this policy for patients presenting with headache that may be caused by Temporal Arteritis, but without a previous history of Giant Cell Arteritis.

The ESR is not indicated in asymptomatic persons (this service is not covered when performed for screening purposes).

Sources of Information and Basis for Decision ^{back to top}

Clinical Laboratory Tests, Values and Implications. Springhouse Corporation

LCD from Carrier, Fiscal Intermediary, Tennessee

LCD from Carrier, Part B, North Carolina

Mosby’s Diagnostic and Laboratory Test Reference. 2nd Edition: 1995.

Taber’s Cyclopedic Medical Dictionary

Advisory Committee Meeting Notes ^{back to top}

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the Intermediary, this policy was developed in cooperation with advisory groups, which include representatives from the affected provider community. Advisory Committee Meeting date: N/A.

Start Date of Comment Period ^{back to top}

06/02/1998

End Date of Comment Period ^{back to top}

07/17/1998

Start Date of Notice Period ^{back to top}

08/21/1998

Revision History Number ^{back to top}

Revision #14, 02/05/2009
Revision #13, 10/01/2008
Revision #12, 10/01/2007
Revision #11, 10/01/2006
Revision #10, 06/06/2005
Revision #9, 11/22/2004
Revision #8, 10/01/2004
Revision #7, 10/01/2003
Revision #6, 12/16/2002
Revision #5, 09/11/2002
Revision #4, 11/12/2001
Revison #3, 05/15/2001
Revision #2, 01/01/2000
Revision #1, 10/15/1999

Revision History Explanation ^{back to top}

Revision #14, 02/05/2009
Under ICD-9 Codes That Support Medical Necessity section ICD-9 code 724.5 was added. This revision becomes effective on 02/05/2009.

Revision #13, 10/01/2008
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2007 to 2008. Under ICD-9 Codes That Support Medical Necessity the following ICD-9 codes were added. 203.02, 203.12, 203.82, 571.42, 780.60, 780.61, 780.64 and 780.65. This revision becomes effective on 10/01/2008.

Revision #12, 10/01/2007
Under AMA/CPT & ADA/CDT Copyright Statement changed the copyright date from 2006 to 2007. Under CMS National Coverage Policy changed the publication number for the cited Change request from “100-8” to now read “100-08”. Under Indications and Limitations of Coverage and/or Medical Necessity 2b corrected a spelling error in the verbiage. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 079.83, 200.30-200.38, 200.40-200.48, 200.50-200.58, 200.60-200.68, 200.70-200.78, 202.70-202.78, 288.66, 415.12, and 449. This policy was reviewed for annual validation. This revision becomes effective 10/01/2007.

Revision #11, 10/01/2006
Under AMA/CPT & ADA/CDT Copyright Statement changed the copyright date from 2005 to 2006. Under Bill Type Codes added 73X bill type. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 288.00-288.09, 288.4, 288.50-288.59, 288.60-288.69, 379.60-379.63, 518.7, 526.61-526.69, 780.32, 780.96 and 780.97.Under Documentation Requirements deleted the first 3 sentences. Under Sources of Information and Basis for Decision the references were placed in the AMA citation format. Under Advisory Committee Meeting Notes the verbiage was revised. This policy was reviewed for annual validation. This revision becomes effective 10/01/2006.

Revision #10, 06/06/2005
Converted the LMRP to a LCD. This revision becomes effective 05/21/2005.

Under CMS National Coverage Policy revised the verbiage for Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). Added Change Request 3010. Under Indications and Limitations of Coverage and /or Medical Necessity verbiage added and revised. Under Revenue Codes revised to read 030X. Under ICD-9 Codes That Support Medical Necessity added multiple ICD-9 codes. Under Documentation Requirements verbiage revised and deleted. Under Utilization Guidelines added verbiage. Under Sources of Information added three references. Under Advisory Committee Notes verbiage changed. This revision becomes effective 06/06/2004.

Revision #9, 11/22/2004
Under AMA CPT Copyright Statement section of the policy, deleted the reference to CDT-4 copyright language, as this policy does not contain CDT-4 codes or descriptions. Under ICD-9 Codes That Support Medical Necessity section of the policy deleted the verbiage related to Appeal rights, as this information will appear on the Palmetto GBA web site under Appeals information. These changes become effective 11/22/2004.

Revision #8, 10/01/2004
Under AMA CPT Copyright Statement section of this policy the copyright date has been updated from 2003 to 2004. Added the American Dental Association copyright statement. Under ICD-9 Codes That Support Medical Necessity section of the policy, added ICD-9 code 066.40-066.49. These changes become effective 10/01/2004.

Revision #7, 10/01/2003
Under AMA CPT Copyright Statement section of this policy the copyright date has been updated from 2002 to 2003. This change goes into effect on 10/01/2003.

Revision #6 12/16/2002
ICD-9-CM code 719.49 has been expanded to 719.41-719.49 in the ICD-9-CM Codes That Support Medical Necessity section of this policy. Effective 01/16/03.

Revision #5 09/11/2002
Under Type of Bill Code section, Critical Access Hospital (85x) has been added to this policy. This Change becomes effective 10/01/02.

Revision #4 11/12/2001
ICD-9-CM codes 274.0-274.9 have been added to the ICD-9-CM Codes That Support Medical Necessity section of this policy.

Revision #3 05/15/2001
The following ICD-9-CM codes have been added to this LMRP: 362.31, 368.11, 369.60, 369.9 and 377.41. The changes will become effective May 15, 2001.

Revision #2 01/01/2000

Revision #1 10/15/1999

This LCD was converted from an LMRP on 5/20/2005

Reason for Change ^{back to top}

ICD9 Addition/Deletion
Maintenance (annual review with new changes, formatting, etc.)

Last Reviewed On Date ^{back to top}

01/26/2009

Medicare Coverage Database

LCD for Sedimentation Rate, Erythrocyte (L1287)