85652
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The submitted CPT/HCPCS code must accurately describe the ESR service performed.
- Maintain the full medical record and make it available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., full name and dates of service).
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
Key Coverage Criteria
- Erythrocyte sedimentation rate (ESR) testing is covered only when reasonable and necessary as defined by Local Coverage Determination L34021.
- ESR performed for rheumatoid arthritis patients to assess the need for medication adjustments should be billed with a diagnosis code that reflects the specific antirheumatic medication the patient is receiving.
- Use ICD-10 codes T39.4X5A–T39.4X5S for ESR billing when the patient with rheumatoid arthritis is receiving antirheumatics such as gold salts for medication evaluation.
- Use ICD-10 codes T45.1X5A–T45.1X5S for ESR billing when the patient with rheumatoid arthritis is receiving antineoplastic or immunosuppressive drugs such as methotrexate for medication evaluation.
- Use ICD-10 codes T45.8X5A–T45.8X5S for ESR billing when the patient with rheumatoid arthritis is receiving other primarily systemic and hematological agents such as heavy metal antagonists for medication evaluation.
- Use ICD-10 codes T50.6X5A–T50.6X5S for ESR billing when the patient with rheumatoid arthritis is receiving antidotes and chelating agents such as penicillamine for medication evaluation.
4 Active Policies
A57657 — Billing and Coding: Sedimentation Rate, Erythrocyte
J09
L34021 — Sedimentation Rate, Erythrocyte
J09
AETNA-CPB-0369 — Chronic Fatigue Syndrome
REGENCE-LAB80 — Screening Laboratory Testing
Related Codes
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