What are the Medicare covered codes for C-Reactive Protein (CRP) tests and homocysteine testing?

Medicare Coverage Codes for CRP and Homocysteine Testing

Medicare covers CRP and homocysteine testing under specific CPT codes when used for cardiovascular risk assessment in appropriate clinical scenarios, but not for general screening purposes.

CRP Testing Coverage

CPT Codes for CRP Testing:

• High-sensitivity CRP (hsCRP) testing is typically coded under:
  • 86141: C-reactive protein; high sensitivity (hsCRP)

Clinical Indications for Coverage:

• Medicare covers hsCRP testing for cardiovascular risk assessment in:
  • Men ≥50 years or women ≥60 years with LDL cholesterol <130 mg/dL 1
  • Patients not on lipid-lowering, hormone replacement, or immunosuppressant therapy
  • Patients without clinical coronary heart disease, diabetes, chronic kidney disease, or severe inflammatory conditions 1
  • Patients at intermediate cardiovascular risk where additional risk stratification would influence treatment decisions 1

Testing Specifications:

• hsCRP assays must be able to detect concentrations down to 0.3 mg/L 1
• Results are typically reported in mg/L (not mg/dL) 1
• Risk stratification categories:
  • Low risk: <1.0 mg/L
  • Average risk: 1.0-3.0 mg/L
  • High risk: >3.0 mg/L 2

Homocysteine Testing Coverage

CPT Codes for Homocysteine Testing:

• 83090: Homocysteine

Clinical Indications for Coverage:

• Medicare coverage for homocysteine testing is more limited than for CRP
• Considered a "second-line" marker for cardiovascular risk assessment 1
• May be covered when used for risk assessment in patients with:
  • Moderate cardiovascular risk profiles 1
  • Family history of premature cardiovascular disease
  • Evidence of atherosclerotic disease without traditional risk factors

Coverage Limitations and Considerations

Frequency Limitations:

• Testing is generally not covered for routine screening in asymptomatic low-risk individuals 1
• Medicare typically limits coverage to once per year for risk assessment purposes

Documentation Requirements:

• Medical necessity must be clearly documented in the patient's record
• The specific cardiovascular risk factors being assessed should be noted
• The rationale for using these biomarkers over standard risk assessment should be included

Coding Challenges:

• Current coding system uses "stacked coding" which doesn't account for individual molecular tests 1
• This can lead to variation in how codes are reported to payors and inconsistent reimbursement 1
• Laboratories may code the same molecular testing differently, increasing the chance for coding errors 1

Clinical Utility Considerations

CRP Testing:

• More established clinical utility than homocysteine
• Adds value when combined with traditional risk factors for cardiovascular risk assessment 1
• Not recommended for general screening in low-risk individuals 1

Homocysteine Testing:

• Has shown precision as an independent risk factor for CVD, but effect is modest 1
• Consistency is often lacking due to nutritional, metabolic, and lifestyle confounders 1
• Intervention studies using B vitamins to reduce plasma homocysteine have not shown reduction in CVD risk 1

Practical Approach to Ordering

1. Determine patient's baseline cardiovascular risk using established risk calculators
2. For intermediate-risk patients, consider adding hsCRP testing first
3. Document specific clinical indication that supports medical necessity
4. Use appropriate CPT codes (86141 for hsCRP, 83090 for homocysteine)
5. Ensure proper documentation of how results will influence clinical management

Remember that Medicare coverage policies may vary by region, and local Medicare Administrative Contractors (MACs) may have specific coverage determinations for these tests.