ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB049

General Inflammation Testing

Rules for reimbursement and clinical use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) testing for inflammatory conditions for Blue Cross Blue Shield of New Mexico providers and members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyGeneral Inflammation Testing

Policy CodePolicy CPCPLAB049

Change TypeCoverage criteria and frequency revisionsadded ESR exclusion for non‑inflammatory conditions

Effective DateNov 1, 2023

Next Review Date

Key ActionDocument ESR is not reimbursable for individuals without a diagnosed inflammatory condition; document test type and clinical indication when ordering.

SourceLink

POLICY UPDATE CHANGES

Reordered the tests so that CRP is listed first due to preference for CRP over ESR.

For individuals without a diagnosed inflammatory condition, measurement of erythrocyte sedimentation rate (ESR) is not reimbursable.

Coverage table introductory statement clarified to specify CRP (conventional or high-sensitivity).

Frequency guidance updated for several conditions (Acute Hematogenous Osteomyelitis, Giant Cell Arteritis, Hodgkin Lymphoma, Rheumatoid Arthritis).

Test preference language changed from 'and' to 'or' for Acute and Chronic Urticaria, Polymyalgia Rheumatica, and Systemic Lupus.

3procedure codes listed

Table 1Conditions and test preferences

several

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Nov 1, 2023plan effective date

Coverage Criteria for CRP and ESR

inv-01: General Coverage Criteria

Covered when testing aligns with a diagnosed or suspected inflammatory condition listed in Table 1 and is not performed in asymptomatic individuals during routine general examinations.

General coverage rules: 1) Measurement of C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR) may be reimbursable for inflammatory conditions noted in Table 1. 2) For individuals without a diagnosed inflammatory condition, measurement of ESR is not reimbursable. 3) Measurement of CRP and/or ESR during general exam without abnormal findings is not reimbursable.

See Table 1 for condition-specific test preference and frequency.

inv-02: Table 1: Condition-specific test preferences and frequencies

Condition-specific guidance (Table 1):

Examples from Table 1: Table 1 lists multiple conditions with specified test preference (CRP, conventional or high-sensitivity CRP, ESR, or both) and recommended frequency. Examples: Acute Hematogenous Osteomyelitis: Test preference = CRP; Frequency = to confirm diagnosis; 2–3 days during early therapy; weekly until normalization or clear trend toward normalization. Periprosthetic Joint Infections: Test preference = CRP and ESR; Frequency = not specified. Rheumatoid Arthritis: Test preference = CRP or ESR; Frequency = prior to treatment; every 1–3 months during active disease; annually when disease is inactive.

Refer to Table 1 for other listed diagnoses and frequencies.

inv-03: Coverage criteria and frequency guidance (summary)

Coverage of ESR, CRP (conventional or high-sensitivity), or both is designated based on the diagnosed or suspected inflammatory condition.

General restriction: Measurement of ESR is not reimbursable for individuals without a diagnosed inflammatory condition.

Explicit exclusion added in policy update.

Test preference updates: CRP (conventional or high-sensitivity) is listed first and is preferred over ESR for many acute inflammatory conditions; for several conditions the policy specifies either CRP or ESR rather than both (policy language changed from 'and' to 'or' for certain diagnoses).

See Table 1 for condition-level designation.

Frequency guidance updates: Frequency recommendations were revised for specific conditions (e.g., Acute Hematogenous Osteomyelitis: confirm diagnosis; 2–3 days during early therapy; weekly until normalization; Giant Cell Arteritis: to confirm diagnosis and during follow-up visits; Rheumatoid Arthritis: added 'annually when disease is inactive').

Exact per-condition frequencies are in Table 1.

Measurement of erythrocyte sedimentation rate (ESR) is explicitly limited to evaluation of persons with a diagnosed or suspected inflammatory condition. The policy states that ESR is not reimbursable for individuals without a diagnosed inflammatory condition, and coverage for CRP and/or ESR otherwise depends on the specific diagnoses and frequencies listed in Table 1.

For clarity of billing and prior authorization decisions, the policy includes the following exclusion: Measurement of ESR is not reimbursable for individuals without a diagnosed inflammatory condition. Claims for ESR in that population may be denied consistent with this rule.

The policy also specifies that measurement of CRP and/or ESR performed during a general physical examination without abnormal findings is not reimbursable. Together with the ESR-specific exclusion for persons without a diagnosed inflammatory condition, these rules define non-covered routine or screening uses of these inflammatory markers.

Operationally, providers should not order ESR for screening or asymptomatic individuals: ESR testing is non-reimbursable when there is no diagnosed inflammatory condition. Ordering and claims should document a covered inflammatory diagnosis per Table 1 when ESR is submitted for reimbursement.

Covered Indications (Table 1 Conditions)

inv-20: Various inflammatory and rheumatologic conditions

Table 1 entries below specify the policy test preference (CRP — conventional or high-sensitivity, ESR, or both) and recommended testing frequency for each condition.

Acute and Chronic Urticaria: Test preference = CRP or ESR; Frequency = Not specified (NS).

Policy revised wording to 'or' for test preference.

Acute Hematogenous Osteomyelitis (AHO): Test preference = CRP; Frequency = To confirm diagnosis; 2 to 3 days during the early therapeutic course; weekly until normalization (or a clear trend toward normalization is evident).

Use CRP to monitor early treatment response.

Ankylosing Spondylitis: Test preference = CRP or ESR; Frequency = Regular interval use in patients with active symptoms.

Use to monitor disease activity in symptomatic patients.

Testing Frequency Guidance

Condition-specific frequencies (Table 1) — examples

Acute Hematogenous Osteomyelitis (AHO)CRP — to confirm diagnosis; 2–3 days during the early therapeutic course; weekly until normalization (or a clear trend toward normalization).

Rheumatoid ArthritisCRP or ESR — prior to treatment; every 1–3 months during active disease; annually when disease is inactive.

Giant Cell ArteritisCRP and ESR — to confirm diagnosis; during follow-up visits.

Periprosthetic Joint Infections (PJI)CRP and ESR — frequency not specified (NS) in Table 1.

Acute Hematogenous Osteomyelitis — frequency guidance

Recommended early monitoringAHO: Repeat testing every 2–3 days during the early therapeutic course to help confirm diagnosis and assess response to initial therapy.

Services Not Covered

Not covered: ESR testing for individuals without a diagnosed inflammatory condition, and CRP and/or ESR testing performed during a general examination when there are no abnormal findings. These are denominated as not reimbursable in the policy’s exclusions and not medically necessary lists.

Restating the exclusion for operational clarity: ESR testing for individuals without a diagnosed inflammatory condition is not covered. Providers should expect denials for ESR claims submitted for asymptomatic members absent a documented inflammatory diagnosis.

Procedure Codes

Procedure Codes listedCPT

85651	Erythrocyte sedimentation rate
85652	Erythrocyte sedimentation rate, automated
86140	C-reactive protein (CRP)

What Providers Must Do

Note

Plan-specific coverage check

BCBSNM has implemented certain lab management reimbursement criteria. Not all requirements apply to each product. Providers are urged to review Plan documents for eligible coverage for services rendered. If a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. If a conflict arises between a CPCP and any provider contract, the provider contract will govern.

Review member-specific plan documents (Certificate of Benefits, Summary Plan Description, benefit booklet) to confirm coverage and any product-specific requirements before ordering or billing for ESR or CRP testing.
BCBSNM may exercise discretion in interpreting and applying this policy; provider contracts and plan documents take precedence where conflicts exist.

Denial Risk

Non-reimbursable scenarios

Measurement of ESR, CRP (conventional or high-sensitivity), or both may be reimbursable only when indicated for a diagnosed or suspected inflammatory condition per Table 1 in the policy. For individuals without a diagnosed inflammatory condition, measurement of ESR is not reimbursable. Measurement of CRP and/or ESR during a general exam without abnormal findings is not reimbursable.

Ordering and Authorization Requirements

Note

Review product-specific ordering and eligibility rules

Review plan documents for product-specific ordering requirements and eligibility; not all policy requirements apply to every BCBSNM product.

Billing Rule

Coverage requires a diagnosed or suspected inflammatory condition; document indication

Order CRP and/or ESR only when there is a diagnosed or suspected inflammatory condition as described in Table 1. The policy ties coverage to a qualifying inflammatory diagnosis or suspicion; no ordering provider-type restrictions are specified in this excerpt.

Ensure the clinical diagnosis or suspected condition is documented on the order and in the medical record.
Follow Table 1 for test preference (CRP, ESR, or both) and frequency recommendations for the specific condition.

Definitions

Definitions — CRP and ESR

CRP definitionC-reactive protein (CRP), conventional or high-sensitivity, is a laboratory marker of inflammation used to detect and monitor inflammatory conditions.

ESR definitionErythrocyte sedimentation rate (ESR) is an indirect laboratory marker of inflammation measured by the rate at which red blood cells sediment.

Clinical preferencePolicy notes a preference for CRP over ESR in several acute inflammatory conditions and lists CRP first in the coverage table.

Alternate definitions and preference guidance — CRP/ESR

CRP (assay types)CRP includes conventional or high-sensitivity assays and should be specified in documentation when applicable.

ESR roleESR is an inflammatory marker that may be used alone or alongside CRP depending on the condition per Table 1.

Background and Rationale

Background: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are acute phase reactants used to evaluate and monitor inflammatory conditions. This policy ties reimbursement to the presence of a diagnosed or suspected inflammatory condition and provides a condition-specific Table 1 that indicates whether CRP (conventional or high-sensitivity), ESR, or both are appropriate and the recommended testing frequency. The policy update reordered the tests to list CRP first to reflect a preference for CRP over ESR in many indications and added the explicit ESR exclusion for persons without a diagnosed inflammatory condition.

Policy Revision History

2023-07-17UpdatedLatest

Document updated with literature review: reordered tests to list CRP first, added ESR reimbursement exclusion for individuals without a diagnosed inflammatory condition, clarified CRP (conventional or high-sensitivity) in Table 1 introductory statement, updated frequency guidance for multiple conditions (Acute Hematogenous Osteomyelitis, Giant Cell Arteritis, Hodgkin Lymphoma, Rheumatoid Arthritis), removed Hypereosinophilic Syndrome from Table 1, and changed test-preference language from 'and' to 'or' for several conditions.

2022-11-01New policy effective

New policy implemented (policy went into effect).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyGeneral Inflammation Testing

Policy CodePolicy CPCPLAB049

Change TypeCoverage criteria and frequency revisionsadded ESR exclusion for non‑inflammatory conditions

Effective DateNov 1, 2023

Next Review Date

Key ActionDocument ESR is not reimbursable for individuals without a diagnosed inflammatory condition; document test type and clinical indication when ordering.

SourceLink

On This Page

Arthritis: Test preference = CRP and ESR; Frequency = 1–3 months initially; 6–12 months later.

Both markers listed for arthritis per table.

Giant Cell Arteritis: Test preference = CRP and ESR; Frequency = To confirm diagnosis; during follow-up visits.

Follow-up testing recommended as clinically indicated.

Hodgkin Lymphoma: Test preference = ESR; Frequency = Every 3–6 months for 1–2 years; every 6–12 months for the next 3 years; annually thereafter.

ESR specified for staging/follow-up intervals.

Periprosthetic Joint Infections (PJI): Test preference = CRP and ESR; Frequency = Not specified (NS).

Both tests listed to aid diagnosis of PJI.

Polymyalgia Rheumatica: Test preference = CRP or ESR; Frequency = At initial diagnosis; every 3 months during long-term steroid therapy.

Either marker acceptable per table.

Rheumatoid Arthritis: Test preference = CRP or ESR; Frequency = Prior to treatment; every 1–3 months during active disease; annually when disease is inactive.

Added annual testing when inactive per update.

Systemic Lupus Erythematosus: Test preference = CRP or ESR; Frequency = At initial assessment; every 1–3 months during active disease; every 6–12 months during stable disease; during pregnancy.

Either marker acceptable; frequency varies by activity.

Irritable Bowel Syndrome: Test preference = CRP and ESR; Frequency = During initial assessment to exclude other diagnoses.

Both tests listed for initial evaluation.

T-cell lymphomas: Test preference = ESR; Frequency = Not specified (NS).

ESR listed for these lymphomas.

inv-21: Multiple diagnosed or suspected inflammatory conditions

When multiple diagnosed or suspected inflammatory conditions are present, the policy designates which test(s) are appropriate based on the condition-specific table entries below.

Use per-condition designation: Coverage of CRP (conventional or high-sensitivity), ESR, or both is determined by the specific condition as listed in Table 1. For conditions where the table lists 'CRP or ESR', either test is acceptable. For conditions listing both CRP and ESR, both tests are appropriate as indicated.

Select tests according to each condition's table entry when multiple conditions coexist.

Priority of CRP: Policy reordered CRP before ESR to reflect preference for CRP in many acute inflammatory conditions; when one condition prefers CRP and another prefers ESR, order tests according to clinical question and documentation to support medical necessity.

Document clinical indication and test type (conventional vs high-sensitivity CRP) when applicable.

ESR exclusion reminder: Measurement of ESR remains not reimbursable for individuals without a diagnosed inflammatory condition even if ordered while evaluating multiple conditions; ensure a documented diagnosed or suspected inflammatory condition is present.

Claims without an appropriate documented indication for ESR may be denied.

Ongoing monitoringAHO: Continue testing weekly until values normalize or a clear trend toward normalization is evident.

PurposeTo confirm diagnosis and monitor therapeutic response during early and ongoing treatment of AHO.

Giant Cell Arteritis — frequency guidance

Diagnostic and follow-up testingGiant Cell Arteritis: CRP and ESR — to confirm diagnosis and during follow-up visits.

Guideline supportFrequency guidance aligns with updated recommendations in 2021 ACR/Vasculitis Foundation guidelines (references cited in policy).

DocumentationSpecify test type (conventional or high-sensitivity CRP) and clinical indication when ordering or submitting claims.

Rheumatoid Arthritis — frequency guidance (clarified)

Initial and active disease monitoringRheumatoid Arthritis: CRP or ESR — prior to treatment; every 1–3 months during active disease.

Stable/inactive disease monitoringRheumatoid Arthritis: Annually when disease is inactive.

PurposeTo assess baseline disease activity before treatment and monitor response and control during active and inactive periods.

ESR will generally be denied for members without a diagnosed inflammatory condition.
CRP and/or ESR obtained as part of a general exam with no abnormal findings are not reimbursable.

Documentation Required

Claims documentation

Providers are responsible for submitting accurate documentation of services performed and must code claims using HIPAA-approved code sets and industry-standard coding guidelines. Claims are subject to code-edit protocols and review against benefit terms, provider contracts, medical and coding policies, and coding software logic. Upon request, providers must submit additional documentation to support medical necessity.

Use appropriate CPT, HCPCS, ICD-10, NDC and other industry-standard codes when billing.
Retain and supply clinical documentation (diagnoses, clinical notes, test indications, and prior test results) when requested to demonstrate medical necessity.
Failure to provide requested documentation may result in claim denial or recoupment.

Documentation Required

Documentation of test type and clinical indication

Document the specific test type and clinical indication on the medical record and, when applicable, on the claim. The policy specifies coverage and test-preference guidance in Table 1 and identifies CRP as conventional or high-sensitivity where applicable.

Specify on the clinical record whether CRP is conventional or high-sensitivity when CRP testing is performed.
Record the diagnosed or suspected inflammatory condition that justifies ESR and/or CRP testing and the intended use (e.g., confirm diagnosis, monitor therapy, exclude other diagnoses).
When ordering repeat testing, document frequency and clinical rationale consistent with the policy's condition-specific guidance (see Table 1).

Preference languageThe policy was updated to list CRP first and to prefer CRP over ESR for certain acute conditions; test preference is designated per condition in Table 1.