CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO49

General Inflammation Testing (CRP and ESR)

This reimbursement policy governs when measurement of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are considered reimbursable by BCBSOK across products governed by plan documents; providers should consult specific plan documents for member eligibility.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyGeneral Inflammation Testing (CRP and ESR)

Policy CodePolicy CPCPLABO49

Change TypeNo material changes

Effective DateNov 1, 2022

Next Review Date

Key ActionSubmit accurate documentation; be prepared to provide additional documentation upon request as claims are subject to review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Concurrent CRP+ESR reimbursablePJI exception

Concurrent not reimbursableGeneral rule

Not reimbursableScreening

ESR reimbursableHodgkin lymphoma

Nov 1, 2022Plan effective

Reimbursement Criteria

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyGeneral Inflammation Testing (CRP and ESR)

Policy CodePolicy CPCPLABO49

Change TypeNo material changes

Effective DateNov 1, 2022

Next Review Date

Key ActionSubmit accurate documentation; be prepared to provide additional documentation upon request as claims are subject to review.

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.

Reimbursement criteria for CRP and ESR

Reimbursement guidance for measurement of CRP and ESR is as follows:

ALL of the following

ONE of
- Measurement of erythrocyte sedimentation rate (ESR) for patients with Hodgkin Lymphoma may be reimbursable.
- Measurement of either C-Reactive Protein (CRP) or ESR in the diagnosis, assessment and monitoring of inflammatory disorders, and/or undiagnosed conditions, and/or to detect acute phase inflammation may be reimbursable.

PJI exception

Concurrent measurement of CRP and ESR may be reimbursable in the diagnosis of periprosthetic joint infections (PJI).

ALL of the following

For any condition other than PJI, measurement of both CRP and ESR at the same visit for diagnosis, assessment, monitoring of inflammatory disorders, undiagnosed conditions, or to detect acute phase inflammation is not reimbursable.
Measurement of either CRP and/or ESR during a general exam without abnormal findings is not reimbursable.

If conflict exists between this policy and a plan document, the plan document governs; provider contracts govern over this policy where applicable.

Not all requirements apply to each product; providers should review plan documents for eligible coverage.

Coding and Concurrent Testing Rules

Coding guidancemixed

No codes listed

Concurrent testing rule — key facts

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

Non-PJI ruleFor any condition other than PJI, measurement of both CRP and ESR at the same visit is not reimbursable.

PJI exceptionConcurrent CRP and ESR may be reimbursable in the diagnosis of periprosthetic joint infections (PJI).

ScopeRule applies to measurement in the diagnosis, assessment, and monitoring of inflammatory disorders, undiagnosed conditions, and to detect acute phase inflammation as noted in the policy.

Documentation and Claims Review

Documentation Required

Documentation and Claims Review — Provider Responsibilities

Providers are responsible for submitting accurate documentation of services performed and must submit claims using valid HIPAA-approved code sets. Claims should be coded according to industry-standard coding guidelines (for example: UB, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG guidelines, CMS NCCI policy manual and CCI table edits). Claims are subject to code edit protocols and review for benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit additional documentation to support the claim.

Affecting code systems: CPT, HCPCS, ICD-10, NDC, DRG
Claims may be reviewed under plan documents, provider contracts, and CPCP
Providers may be asked to provide additional documentation upon request

Key Definitions

PJI — periprosthetic joint infection exception

PJI definition (policy term)Periprosthetic joint infection (PJI) is identified in the policy as the specific clinical scenario that permits concurrent measurement of CRP and ESR.

Exception scopeConcurrent CRP+ESR reimbursable when used in the diagnosis of periprosthetic joint infections (PJI).

Exception limitationThe PJI exception does not extend to other conditions; for non-PJI conditions, concurrent testing at the same visit is not reimbursable.

Related reimbursement noteMeasurement of either CRP or ESR (but not both at the same visit) may be reimbursable for other inflammatory indications per policy criteria.