CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO49

General Inflammation Testing (CRP and ESR) Reimbursement

This BCBSNM clinical payment and coding policy (CPCPLABO49) governs reimbursement criteria for measurement of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) across BCBSNM products; providers and claims administrators should follow plan documents and provider contracts for coverage determination.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyGeneral Inflammation Testing (CRP and ESR) Reimbursement

Policy CodePolicy CPCPLABO49

Change TypeNew policy

Effective DateJan 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and claims using valid HIPAA-approved code sets; claims may be reviewed and require additional documentation.

SourceLink

POLICY UPDATE CHANGES

New policy

1ESR reimbursable for Hodgkin Lymphoma

2Either CRP or ESR reimbursable for inflammatory disorders

3Concurrent CRP+ESR reimbursable for PJI

4Both tests at same visit not reimbursable (non-PJI)

5Testing during general exam without findings not reimbursable

Reimbursement Criteria for ESR and CRP

ESR/CRP reimbursement criteria

Covered when the following specific conditions are met:

ALL of the following

ONE of
- One measurement of erythrocyte sedimentation rate (ESR) for patients with Hodgkin Lymphoma may be reimbursable.
  Medical record documentation of Hodgkin Lymphoma diagnosis should be available.
- Measurement of either C‑Reactive Protein (CRP) or ESR for the diagnosis, assessment, or monitoring of inflammatory disorders, undiagnosed conditions, or to detect acute phase inflammation may be reimbursable.
  Clinical indication supporting inflammatory disorder or undiagnosed condition should be documented.
Concurrent testing

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyGeneral Inflammation Testing (CRP and ESR) Reimbursement

Policy CodePolicy CPCPLABO49

Change TypeNew policy

Effective DateJan 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and claims using valid HIPAA-approved code sets; claims may be reviewed and require additional documentation.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Concurrent Testing Rules

Coding guidancemixed

Claims should be coded using HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG, etc.) per industry standard guidance

Concurrent testing rule

Concurrent testing ruleConcurrent measurement of CRP and ESR is reimbursable only for diagnosis of periprosthetic joint infection (PJI); for any condition other than PJI, measurement of both CRP and ESR at the same visit is not reimbursable.

Required documentation for PJIDocumentation supporting suspicion or evaluation for periprosthetic joint infection must be submitted to support reimbursement for concurrent CRP and ESR.

Other conditionsFor inflammatory disorders, undiagnosed conditions, or acute phase inflammation, only one of CRP or ESR may be reimbursable unless evaluating for PJI.

Documentation and Claims Submission Requirements

Documentation Required

Submit accurate documentation and use HIPAA‑approved codes; respond to claim review requests

Providers must submit accurate documentation of services performed and submit claims using valid HIPAA‑approved code sets (for example CPT, HCPCS, ICD‑10, NDC, DRG) in accordance with industry coding guidelines. Claims are subject to code edit protocols and may be reviewed against benefit terms, provider contract language, medical and clinical payment/coding policies; upon request providers must submit additional documentation to support the claim.

Use HIPAA‑approved code sets and industry standard coding guidelines (CPT, HCPCS, ICD‑10, NDC, DRG, etc.)
Claims are subject to code edit protocols and claim review including benefit coverage, provider contract, medical policies, and coding software logic
If requested, submit any additional documentation to support payment

OpenPayer

General Inflammation Testing (CRP and ESR) Reimbursement

Reimbursement Criteria for ESR and CRP

Coding and Concurrent Testing Rules

Documentation and Claims Submission Requirements

Plan Documents and Governing Coverage