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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}

L26151

LCD Title ^{back to top}
High Sensitivity C- Reactive Protein Testing

Contractor's Determination Number ^{back to top}
07A-0009-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. Title XVIII of the Social Security Act, §1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. 42 CFR, §410.28 Hospital or CAH diagnostic services furnished to outpatients: Conditions 42 CFR, §410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions 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

Secondary Geographic Jurisdiction ^{back to top}


Oversight Region ^{back to top}
Region IV

Original Determination Effective Date ^{back to top}
For services performed on or after 10/15/2007

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 07/31/2008

Revision Ending Date ^{back to top}
09/02/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Among Medicare’s statutory and regulatory coverage requirements for diagnostic services, is the requirement that diagnostic tests be reasonable and necessary. Additionally the ordering physician must use the test results in the management of the beneficiary’s specific medical problem. The utility of using high sensitivity C-reactive protein (hs-CRP), in addition to more conventional cardiovascular risk factors, has yet to be demonstrated. Palmetto GBA has, therefore, made the determination that payment for hs-CRP is excluded from Medicare coverage, and by definition not reasonable and necessary.

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
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}

86141 C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP)

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

N/A

XX000 Not Applicable

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}

N/A

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

Miller M, et al. High attributable risk of elevated C - reactive protein level to conventional coronary heart disease risk factors. Arch Intern Med. 2005; 165:2063-2068.

Pearson TA, et al. Markers of inflammation and cardiovascular disease; application to clinical and public health practice; a statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation. 2003:107(3):499-511.

Wang TJ, et al. Multiple biomarkers for the prediction of first major cardiovascular events and death. N Engl J Med. 2006; 355:2631-2639.

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}

07/05/2007

End Date of Comment Period ^{back to top}

08/20/2007

Start Date of Notice Period ^{back to top}

08/29/2007

Revision History Number ^{back to top}

Revision #2, 07/31/2008
Revision #1, 10/15/2007

Revision History Explanation ^{back to top}

Revision #2, 07/31/2008
This was the annual validation. This revision becomes effective on 07/31/2008.

Revision #1, 10/15/2007
No comments were received during the comment period. The notice period became effective 08/29/2007. This policy becomes effective 10/15/2007.

2/18/2008 - The description for Bill code 21 was changed

Reason for Change ^{back to top}

Maintenance (annual review with new changes, formatting, etc.)

Last Reviewed On Date ^{back to top}

07/15/2008

Medicare Coverage Database

LCD for High Sensitivity C- Reactive Protein Testing (L26151)