Pathology/Lab Coding Alert

Question: When our lab performs an erythrocyte sedimentation rate that the physician uses to confirm an osteoarthritis (as opposed to rheumatoid arthritis) diagnosis, how can we get the insurer to pay for the test if they only cover ESR for inflammatory disease?

South Carolina Subscriber

Answer: Laboratories should bill clinical tests using the ordering diagnosis, not the final diagnosis that the physician assigns based on the test results. That means your lab's payment for an ESR should not depend on the final osteoarthritis (715.xx) or rheumatoid arthritis (714.0) diagnosis.

Physicians may order an ESR based on inflammatory disease symptoms or to assess rheumatoid arthritis patients- prognosis or treatment. Many carriers and insurers have policies concerning what diagnoses and symptoms demonstrate medical necessity for this test.

For instance: National Government Services Inc. has an ESR local coverage determination (LCD) that lists osteoarthritis (such as 715.00, Osteoarthritis, generalized; site unspecified) and rheumatoid arthritis (714.0), as well as numerous symptoms such as fever (780.6) and weight loss (783.21), as payable diagnoses for the test.

Bottom line: Report your lab's ESR test with the appropriate code based on whether your lab performs an automated test:

- 85651 -- Sedimentation rate, erythrocyte; non-automated

- 85652 -- - automated.

And use the physician's ordering diagnosis. You can check with payers to see which diagnoses demonstrate medical necessity.