Pathology/Lab Coding Alert

Question: Our lab often gets orders from a local cardiology practice for C-reactive protein, but payment for the test is inconsistent. What could be the reason that we get a spate of denials for the test?


Iowa Subscriber

Answer: The answer to your question almost certainly lies in the reason the physician ordered the test and your payers- coverage rules -- in other words, medical necessity.
 
Although recent studies have linked inflammation of coronary arteries to cardiovascular disease, as measured non-specifically by high sensitivity C-reactive protein, payers have not reached consensus about covering the test.

When Medicare established heart-disease screening guidelines in 2004, CMS did not list 86141 (C-reactive protein; high sensitivity [hsCRP]) as a covered code, despite the urging of some professional societies to include  the test.

In fact, some carriers consider the test screening -- and therefore non-covered -- even if the patient shows some signs of cardiovascular disease. Noridian Administrative Services, LLC -- your Medicare carrier in Iowa -- states that it considers hsCRP a screening test -in the absence of a clear indication that - the test - altered significantly the patient's diagnosis or treatment plan,- even for patients presenting with symptoms of ischemic  heart disease.

Other carriers allow the test under certain circumstances: NHIC-California -considers hsCRP (86141) for payment as part of the overall evaluation and treatment plan indicated for the signs or symptoms of disease.-

Discuss coverage rules with your carrier and other payers, and inform your cardiology clients of your findings. If the cardiologists persist in ordering the test without a payable diagnosis, ensure that the patient receives an Advance Beneficiary Notice (ABN) and is aware that he or she will be responsible to pay for the test.

-- Reader Questions and You Be the Coder were prepared with the assistance of R. M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark.