LCD : Rheumatoid Factor Test (L1628)

LCD for Rheumatoid Factor Test (L1628)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1628

LCD Title

Rheumatoid Factor Test

Contractor's Determination Number

1628

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 10/16/1997

Original Determination Ending Date

Revision Effective Date

For services performed on or after 12/08/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with altered IgG). Useful in the confirmation of the diagnosis of rheumatiod arthritis when clinical examination is not conclusive.

Rheumatoid factor testing is medically indicated for those patients whose clinical diagnosis is highly suspicious for rheumatoid arthritis and the blood test is needed for confirmation. The patient's treatment course would be dependent upon the outcome of the test.

The Rheumatoid Factor (RF) blood test would be medically indicated after the clinical examination proves unable to distinguish between Rheumatoid Arthritis and the following conditions:

Chronic Interstitial Fibrosis
Chronic Hepatitis disease
Infectious Mononucleosis
Leprosy
Polymyositis
Sarcoidosis
Scleroderma
Subacute Bacterial Endocarditis
Syphilis
Systemic Lupus Erythematosus
Tuberculosis

The physician may order a quantitative and/or a qualitative test based on his clinical judgement. There is no medical necessity for a qualitative and quantitative test in the same encounter unless the treating physician ordered the quantitative test only after receiving the (positive) results of the qualitative. If the physician orders a test without specifying quantitative or qualitative, the lab may perform and bill for either test based on their internal protocols but may not bill for both. In this case, and in the case where the physician simultaneously orders both qualitative and quantitative, the qualitative test would be a bundled service with the quantitative.

Coverage Topic

Lab Services

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

030X	Laboratory-general classification
031X	Laboratory pathological-general classification

CPT/HCPCS Codes

86430	RHEUMATOID FACTOR; QUALITATIVE
86431	RHEUMATOID FACTOR; QUANTITATIVE

ICD-9 Codes that Support Medical Necessity

015.00 - 015.26	TUBERCULOSIS OF VERTEBRAL COLUMN UNSPECIFIED EXAMINATION - TUBERCULOSIS OF KNEE TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
015.80 - 015.96	TUBERCULOSIS OF OTHER SPECIFIED JOINT UNSPECIFIED EXAMINATION - TUBERCULOSIS OF UNSPECIFIED BONES AND JOINTS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
030.9	LEPROSY UNSPECIFIED
075	INFECTIOUS MONONUCLEOSIS
095.8	OTHER SPECIFIED FORMS OF LATE SYMPTOMATIC SYPHILIS
135	SARCOIDOSIS
273.2	OTHER PARAPROTEINEMIAS
274.0	GOUTY ARTHROPATHY
421.9	ACUTE ENDOCARDITIS UNSPECIFIED
443.0	RAYNAUD'S SYNDROME
446.5	GIANT CELL ARTERITIS
516.3	IDIOPATHIC FIBROSING ALVEOLITIS
571.9	UNSPECIFIED CHRONIC LIVER DISEASE WITHOUT ALCOHOL
701.0	CIRCUMSCRIBED SCLERODERMA
710.0 - 710.4	SYSTEMIC LUPUS ERYTHEMATOSUS - POLYMYOSITIS
710.9	UNSPECIFIED DIFFUSE CONNECTIVE TISSUE DISEASE
711.10 - 711.19	ARTHROPATHY SITE UNSPECIFIED ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS - ARTHROPATHY INVOLVING MULTIPLE SITES ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS
711.20 - 711.29	ARTHROPATHY IN BEHCET'S SYNDROME SITE UNSPECIFIED - ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING MULTIPLE SITES
711.30 - 711.39	POSTDYSENTERIC ARTHROPATHY SITE UNSPECIFIED - POSTDYSENTERIC ARTHROPATHY INVOLVING MULTIPLE SITES
712.10 - 712.39	CHONDROCALCINOSIS DUE TO DICALCIUM PHOSPHATE CRYSTALS INVOLVING UNSPECIFIED SITE - CHONDROCALCINOSIS CAUSE UNSPECIFIED INVOLVING MULTIPLE SITES
712.80 - 712.99	OTHER SPECIFIED CRYSTAL ARTHROPATHIES SITE UNSPECIFIED - UNSPECIFIED CRYSTAL ARTHROPATHY INVOLVING MULTIPLE SITES
713.0 - 713.6	ARTHROPATHY ASSOCIATED WITH OTHER ENDOCRINE AND METABOLIC DISORDERS - ARTHROPATHY ASSOCIATED WITH HYPERSENSITIVITY REACTION
714.0 - 714.2	RHEUMATOID ARTHRITIS - OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT
714.30 - 714.33	CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS - MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS
714.4	CHRONIC POSTRHEUMATIC ARTHROPATHY
714.81	RHEUMATOID LUNG
714.89	OTHER SPECIFIED INFLAMMATORY POLYARTHROPATHIES
714.9	UNSPECIFIED INFLAMMATORY POLYARTHROPATHY
725	POLYMYALGIA RHEUMATICA

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

Documentation supporting medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims without such evidence will be denied.

This policy should be interpreted to incorporate future changes in the HCPCS/CPT, and ICD-9 coding systems such that the original intent will not change.

Appendices

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines

Sources of Information and Basis for Decision

Carrier Policy

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period

08/01/1997

End Date of Comment Period

Start Date of Notice Period

09/15/1997

Revision History Number

051-97k

Revision History Explanation

08/05/2003 Under the Indications and Limitations section,
REPLACED this paragraph "Medicare would not expect to see the quantitative test performed for patients highly suspected of having Rheumatoid Arthritis, without a positive qualitative test" WITH ""The physician may order a quantitative and/or a qualitative test based on his clinical judgement. There is no medical necessity for a qualitative and quantitative test in the same encounter unless the treating physician ordered the quantitative test only after receiving the (positive) results of the qualitative. If the physician orders a test without specifying quantitative or qualitative, the lab may perform and bill for either test based on their internal protocols but may not bill for both. In this case, and in the case where the physician simultaneously orders both qualitative and quantitative, the qualitative test would be a bundled service with the quantitative."

01/10/2003 Added 12x to Type of Bill Code

07/24/2002 Formatted

01/05/2001 updated ICD-9 and CPT codes with 2001 edition

This LCD was converted from an LMRP on 12/7/2005

7/2/2006 - The description for Bill code 14 was changed

10/30/2007 - Frequently Asked Questios restored to Appendices

Reason for Change

Last Reviewed On Date

10/30/2007

Related Documents

Article(s)
A37894 - Rheumatoid Factor Test

LCD Attachments

FAQ - Comment and Response (889 bytes)

Other Versions

Updated on 09/05/2006 with effective dates 12/08/2005 - N/A

Updated on 07/02/2006 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 08/05/2003 - 12/07/2005

Updated on 09/09/2003 with effective dates 08/05/2003 - N/A

Updated on 08/01/2003 with effective dates 08/05/2003 - N/A

Updated on 03/11/2003 with effective dates 01/10/2003 - 08/04/2003

Updated on 02/15/2003 with effective dates 01/10/2003 - N/A

Updated on 01/09/2003 with effective dates 01/10/2003 - N/A

Updated on 10/04/2002 with effective dates 07/24/2002 - 01/09/2003