C-Reactive Protein: Cahaba GBA Coverage and Documentation Requirements

on Tuesday, 03 November 2009. All News Items

Cahaba GBA, Medicare Administrative Contractor (MAC) for Alabama, Georgia and Tennessee, recently released an article and a draft Local Coverage Determination (LCD) regarding the laboratory tests for C-Reactive Protein (CRP).

The CRP Article discusses the appropriate medical record documentation and correct billing of CRP and high sensitivity CRP.  Medical record data analysis and review identified documentation errors related to CRP (CPT code 86140) for Type of Bill 13X.  Documentation errors in the medical records submitted for review included

  • lack of documentation to support that labs were ordered by the treating physician (such as no orders or unsigned orders),
  • lack of documentation to support medical necessity, and
  • no documentation of CRP test results.

The article also stated that high-sensitivity CRP (CPT 86141) is not covered by Medicare for screening, prevention, risk stratification, or diagnosis of cardiovascular disease.  It is also not supported for diagnostic purposes.

The article reminds providers that orders for diagnostic tests must be written and signed by the treating physician/practitioner requesting the test.  Documentation to support billing should include the signed order, patient information, diagnosis, the name of the test(s), test results, and any other documentation that substantiates the services.

Denials may also occur if records are not submitted or are not submitted timely.  MMP, Inc. reminds providers to have a process in place to identify and respond to ADR requests in a timely and complete manner.

Draft Local Coverage Determination

Cahaba GBA is currently accepting public comment on the draft LCD for CRP, High Sensitivity CRP and Erythrocyte Sedimentation Rate (ESR).  The draft LCD identifies CRP and ESR as non-specific diagnostic tests for the detection and evaluation of infection, tissue injury, and inflammatory disease; CRP and ESR should not be billed concurrently.  Per the draft LCD, “When a CRP and ESR are billed concurrently, one service will be denied.”

The draft LCD also states that high sensitivity CRP (CPT code 86141) is a non-covered service since it is not supported for screening or monitoring of cardiovascular disease.

A copy of the draft LCD is attached.  Providers may submit comments on the draft LCD until December 1, 2009 to This email address is being protected from spambots. You need JavaScript enabled to view it.

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