Coding, Classification & Reimbursement

C-Reactive Protein 86140

  • 1.  C-Reactive Protein 86140

    Posted 04-18-2018 16:58
    ​​We recently have been told that Medicare is no longer covering C-Reactive Protein  (86140) lab test.  There are no covered diagnoses that we can find, just non covered.  There was a reference to MOlDX in an article that I read but honestly didn't understand it.  Has anyone else ran into this situation and found a solution?  Thanking you in advance. And yes, I plan to ask the laboratory manager as soon as she gets back from vacation.

    ------------------------------
    Nelda Laskey RHIT
    Coder/RAC Coordinator
    Kearny County Hospital
    ------------------------------


  • 2.  RE: C-Reactive Protein 86140

    Posted 04-18-2018 17:01
    ​We have the same thing going on here - it was effective 1/30/2018.  I have found no solution.

    ------------------------------
    Joan Zier
    Coder
    ------------------------------



  • 3.  RE: C-Reactive Protein 86140

    Posted 04-19-2018 09:19
    ​What I find within the WPS website is a non-coverage document for the Local Coverage Determination (LCD):
    MolDX: Prometheus IBD sgi Diagnostic Policy (L37539). https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37539.      Basically this refers to tests for diagnosing IBD versus Crohn's disease.   I have also found that 86041 is covered in the MoIDX coverage determinations for cardiovascular disease, rather than 86040.   However, I don't find any indication that a CRP is a non-covered test by Medicare.   Are you saying the test isn't covered for symptoms such as fever, lymphadenopathy, joint pain, etc. which have been some of the primary indications for which it was frequently ordered?   There is no NCD, so I'm having difficulty determining how Medicare would edit for this, other than any coverage documents which cover only specific dx code/CPT code combinations.  Thanks!



    ------------------------------
    Susan Roehl
    Consultant
    ------------------------------



  • 4.  RE: C-Reactive Protein 86140

    Posted 04-20-2018 11:01

    There are no listed diagnosis in the LCD that will cover this test. 



    ------------------------------
    Joan Zier
    Coder
    ------------------------------



  • 5.  RE: C-Reactive Protein 86140

    Posted 04-20-2018 12:45
    ​Our lab manager knew about the MolDX and a Z-code which she had contacted McKesson or some web site to obtain the Z code.  However, she tried to obtain a z-code for the 86140 but there is not an available z-code which the lab manager was not surprised.  So I am rather confused with this whole issue as it doesn't make sense.  My only thought is: Did CMS make a typo and 86140 doesn't belong in the L37539 LCD? Surely the 3 of us aren't the only ones that this is happening to.  We are in Kansas and I think our effective date was March 19, 2018 for LCD L37539.

    ------------------------------
    Nelda Laskey RHIT
    Coder/RAC Coordinator
    Kearny County Hospital
    ------------------------------



  • 6.  RE: C-Reactive Protein 86140

    Posted 04-20-2018 12:52
    ​We are having the same issue as well.  On LCD L36523 86141 is listed but not 86140 so I thought it was just a mistake somewhere and just denying this.  I have sometimes been able to add E785 and get it covered but not yet finding a reason for why all of a sudden this is denying.  All of our patients who have RA get this test done occasionally and they are all getting denied.  I'm still looking for an answer, our physicians don't understand it either.

    ------------------------------
    Angela Hittner
    Pike County Memorial Hospital
    ------------------------------



  • 7.  RE: C-Reactive Protein 86140

    Posted 05-14-2018 14:21
    ​Has anyone discovered anything new on this or why this is happening yet?  I haven't seen a reply to this thread in a while and we are still fighting this, I am wondering if anyone has any answers or solutions yet.   Joanie

    ------------------------------
    Joan Zier
    Coder
    ------------------------------



  • 8.  RE: C-Reactive Protein 86140

    Posted 05-15-2018 09:05
    This must be a coverage issue for certain MACs, as NGS (WI) does not have local coverage expectations.  I don't see an NCD either.
    Overall, this code is SI Q4 - which means it's conditionally packaged when reported with other SIs, such as J1, J2, S, T, V, Q1, Q2, and Q3.  Therefore, if you are a PPS hospital, there will be no payment for this test when performed with many outpatient encounters.....regardless of the presence/lack of an LCD.
    IF reported independently on the claim (without any other service with aforementioned SIs,) the lab test is paid under the fee schedule and I assume your LCD would then be in effect for coverage.

    ------------------------------
    Sheila Goethel
    Coding Services Senior Manager
    ------------------------------



  • 9.  RE: C-Reactive Protein 86140

    Posted 05-16-2018 18:58
    We are in Kansas and WPS is our Medicare carrier.  I found a "contact" on WPS website and asked the question about C-Reactive Protein.  I received a phone call from a lady and she said the test is not covered.  I kept asking if covered in certain other instances and all she would say was that the test is non covered.  It is my understanding nothing will get the test paid.  Unbelievable!!!

    ------------------------------
    Nelda Laskey RHIT
    Coder/RAC Coordinator
    Kearny County Hospital
    ------------------------------