Medical_Policy

Medicare Advantage Medical Policy Bulletin

Section:	Laboratory
Number:	L-69
Topic:	C-Reactive Protein
Effective Date:	July 21, 2008
Issued Date:	July 21, 2008

General Policy

C-reactive protein (CRP) is an acute phase reactant produced by the liver that has been used to monitor inflammatory processes, such as infection and autoimmune disease.

Indications and Limitations of Coverage

High Sensitivity CRP (86141) – Current literature does not support the use of high sensitivity CRP (86141), for diagnostic purposes at this time. High sensitivity CRP testing is not covered for screening, prevention or risk stratification of cardiovascular disease. This is a non-coverage policy for high sensitivity C-reactive Protein. When reported, code 86141 will be denied as investigational. A provider can bill the member for the denied service.
Standard Sensitivity CRP (86140) - Currently, standard sensitivity CRP (CPT 86140) is covered as a diagnostic test for the detection and evaluation of infection, tissue injury and inflammatory disease. The results of these diagnostic tests must show an impact to the patient’s care plan.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on the claim, and documentation must be available on request.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

86140

86141

Coding Guidelines

Publications

References

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 1862(a)(1)(A) states that no 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 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

www.cms.gov

www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.