M35.1 — Other overlap syndromes
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
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.
19 Active Policies
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
L39139 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J06
A58893 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J06
Related Codes
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