Billing and Coding: High Sensitivity C-Reactive Protein (hsCRP)

This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33908 High Sensitivity C-Reactive Protein (hsCRP) provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to the LCD for reasonable and necessary requirements and limitations. The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD. Coding Guidelines Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. Medical record documentation maintained by the ordering/referring physician/qualified nonphysician practitioner must indicate the medical necessity for performing the test and the test results. In addition, if the service exceeds the frequency parameter listed in the LCD, documentation of medical necessity must be submitted upon request. If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain a copy of test results, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the test. The clinical indication/medical necessity for the test must be indicated in the order for the test. Utilization Guidelines In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. Compliance with the provisions in LCD L33908, High Sensitivity C-Reactive Protein (hsCRP) may be monitored and addressed through post payment data analysis and subsequent medical review audits.