L28983-LCD

Automated World Health

Local Coverage Determination (LCD) for Sedimentation Rate, Erythrocyte (L28983)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28983

LCD Title Sedimentation Rate, Erythrocyte

Contractor's Determination Number A85651

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 03/07/2012

Revision Ending Date

CMS National Coverage Policy

Medicare Benefit Policy Manual, Chapter 15, section 80

42 CFR 410.32 – Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions

Indications and Limitations of Coverage and/or Medical Necessity

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.

Medicare will consider an ESR medically reasonable and necessary for one of the following conditions:

• Aiding in the diagnosis of temporal arteritis (giant cell arteritis) and polymyalgia rheumatica

• 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

Coding Information

Bill Type Codes:

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.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

085x Critical Access Hospital

Revenue Codes:

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.

0305 Laboratory - Hematology

CPT/HCPCS Codes

85651 SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED

85652 SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED

ICD-9 Codes that Support Medical Necessity

200.20 - 200.28

201.00 - 201.98

202.00 - 202.08

202.80 - 202.88

240.0 - 240.9

BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES

NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES

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

ACUTE THYROIDITIS - THYROIDITIS UNSPECIFIED

245.0 - 245.9 opens in new window

246.8 OTHER SPECIFIED DISORDERS OF THYROID

279.41 - 279.49

AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME - AUTOIMMUNE DISEASE, NOT ELSEWHERE CLASSIFIED

285.29 ANEMIA OF OTHER CHRONIC DISEASE

285.9 ANEMIA UNSPECIFIED

362.34 TRANSIENT RETINAL ARTERIAL OCCLUSION

379.91 PAIN IN OR AROUND EYE

391.1 ACUTE RHEUMATIC PERICARDITIS

391.2 ACUTE RHEUMATIC ENDOCARDITIS

391.3 ACUTE RHEUMATIC MYOCARDITIS

391.8 OTHER ACUTE RHEUMATIC HEART DISEASE

410.00 - 410.92

ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE

446.0 POLYARTERITIS NODOSA

446.5 GIANT CELL ARTERITIS

447.6 ARTERITIS UNSPECIFIED

556.0 - 556.9 opens in

new window ULCERATIVE (CHRONIC) ENTEROCOLITIS - ULCERATIVE COLITIS UNSPECIFIED

696.0 PSORIATIC ARTHROPATHY

710.1 SYSTEMIC LUPUS ERYTHEMATOSUS

710.2 SYSTEMIC SCLEROSIS

710.3 SICCA SYNDROME

710.4 POLYMYOSITIS

710.9 UNSPECIFIED DIFFUSE CONNECTIVE TISSUE DISEASE

714.1 RHEUMATOID ARTHRITIS

714.2 FELTY'S SYNDROME

714.3 OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT

714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.81 RHEUMATOID LUNG

714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

716.59 UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING MULTIPLE SITES

719.49 PAIN IN JOINT INVOLVING MULTIPLE SITES

720.0 ANKYLOSING SPONDYLITIS

725 POLYMYALGIA RHEUMATICA

729.1 MYALGIA AND MYOSITIS UNSPECIFIED

733.99 OTHER DISORDERS OF BONE AND CARTILAGE

783.21 LOSS OF WEIGHT

784.0 HEADACHE

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

* According to the ICD-9-CM book, diagnosis codes E933.1, E933.8, E935.6, and E947.2 are secondary diagnosis codes and must not be billed as the primary diagnosis.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Documentation must support reason for ESR and should include a history and physical, progress notes, and lab reports. This service is not medically necessary for screening purposes.

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.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

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

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2009

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:04/01/2012 Revised Effective Date:03/07/2012

LCR A2012-025

March 2012 Connection

Explanation of Revision: LCD was revised to add diagnosis codes 285.29 and 285.9 to the “ICD-9 Codes that Support Medical Necessity” section of the LCD. In addition, verbiage was added to indicate that diagnosis codes E933.1, E933.8, E935.6, and E947.2 are secondary diagnoses and must not be billed as primary diagnoses. The effective date of this revision is for claims processed on or after 03/07/2012, for dates of service on or after 01/12/2004.

Revision Number:1

Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR A2009-081

September 2009 Bulletin

Explanation of Revision: Annual 2010 ICD-9-CM Update. Deleted diagnosis code 279.4 and replaced with diagnosis code range 279.41-279.49. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28983) replaces LCD L1167 as the policy in notice. This document (L28983) is effective on 02/16/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 8/1/2010 - The description for Bill Type Code 12 was changed

8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0305 was changed

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

85651 descriptor was changed in Group 1 85652 descriptor was changed in Group 1

Reason for Change Typographical Correction