CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLABOSS

Parathyroid Hormone, Phosphorous, Calcium and Magnesium Testing

Defines reimbursement criteria and frequencies for serum intact parathyroid hormone (PTH) and related calcium, phosphorus and magnesium laboratory tests for Blue Cross Blue Shield of Illinois members; applies to providers submitting claims to BCBSIL and to affected plan members.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyParathyroid Hormone, Phosphorous, Calcium and Magnesium Testing

Policy CodePolicy CPCPLABOSS

Change TypeNew policy

Effective DateJan 1, 2026

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

New policy establishing lab management reimbursement criteria for PTH, phosphorus, calcium and magnesium testing.

1.0policy version

2025-09-05approval date

2026-01-01effective date

newupdate history

Reimbursement Criteria for PTH and Related Tests

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyParathyroid Hormone, Phosphorous, Calcium and Magnesium Testing

Policy CodePolicy CPCPLABOSS

Change TypeNew policy

Effective DateJan 1, 2026

Next Review Date

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

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.

PTH and related electrolyte testing reimbursement criteria

Reimbursable indications and permitted testing frequencies for serum intact parathyroid hormone (PTH) and related electrolyte tests are as follows.

ALL of the following

ANY of the following
- Individuals with abnormal calcium levels.
- One-time testing for diagnosis of hypoparathyroidism when signs of hypoparathyroidism are present (see Note 1).
- Individuals who have undergone parathyroidectomy.
- Individuals with osteoporosis or low bone mass.
ALL of the following
- Individuals diagnosed with hyperparathyroidism who have not undergone parathyroidectomy: one test every year.
- Chronic kidney disease (CKD): Grade 3 — one test every 12 months.
- Chronic kidney disease (CKD): Grade 4 or Grade 5 — one test every 3 months.
- Pseudohypoparathyroidism and related disorders (see Note 2): one-time testing for individuals with multiple endocrine neoplasia type 2A or familial medullary thyroid carcinoma; for individuals <18 years — one test every 3 months; for individuals ≥18 years — one test every year.

ALL of the following

Serum intact PTH testing to screen asymptomatic individuals for hyperparathyroidism is not reimbursable.
For wellness or general exams without abnormal findings, the following tests are not reimbursable: serum phosphorus/phosphate; serum, blood, or fecal magnesium; urine phosphorus/phosphate; serum parathyroid hormone; serum total calcium, serum ionized calcium, or urine calcium.
Testing serum for truncated PTH metabolites (aminoterminal and carboxy-terminal fragments) is not reimbursable.

ALL of the following

Elevated serum phosphorus.
Low calcitriol.
Hypercalciuria.
Abnormal magnesium.

ALL of the following

Pseudohypoparathyroidism Type 1B (PHP1B) — due to methylation defect at the GNAS coding sequence.
Pseudohypoparathyroidism Type 1A (PHP1A) — due to maternal loss of function mutation at the GNAS coding sequence.
Pseudopseudohypoparathyroidism (PPHP) — due to paternal loss of function mutation at the GNAS coding sequence.
Progressive Osseous Heteroplasia (POH) — due to paternal loss of function mutation at the GNAS coding sequence.
Acrodysostosis (ACRDYS1) — due to mutation in PRKAR1A.
Acrodysostosis (ACRDYS2) — due to mutation in PDE4D.

Procedure Codes and Frequency Guidance

Procedure codes notemixed

Policy includes procedure code list but states it is not exhaustive; inclusion does not guarantee coverage.

PTH testing frequency by condition — Varies by condition (see coverage criteria)

General rulePTH testing frequency varies by clinical condition; see coverage criteria for specific frequencies.

Hyperparathyroidism (no parathyroidectomy)One test every year.

Chronic kidney disease (Grade 3)One test every 12 months.

Chronic kidney disease (Grade 4 or 5)One test every 3 months.

Pseudohypoparathyroidism/related disordersAge <18: one test every 3 months; Age ≥18: one test every year.

Documentation and Claims Submission Requirements

Documentation Required

Submit accurate documentation and HIPAA‑approved coded claims; additional documentation may be requested

Providers must submit accurate documentation of services performed and submit claims using valid code combinations from HIPAA‑approved code sets. Claims should be coded according to industry standard coding guidelines (for example, UB, AMA CPT, HCPCS, ICD‑10‑CM/PCS, DRG guidance, CMS NCCI edits). BCBSIL may request additional documentation and may review drug submissions against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.

Use valid HIPAA‑approved code sets and appropriate code combinations when submitting claims.
Code claims per industry standard coding guidelines (Uniform Billing, AMA CPT, HCPCS, ICD‑10‑CM/PCS, DRG, CMS NCCI, etc.).
Be prepared to provide additional documentation upon BCBSIL request; drug submissions may be subject to further review against benefit/contract/policy terms and coding logic.

Definitions and Related Disorders

Plan criteria — Lab management reimbursement criteria

Plan criteria (definition)Lab management reimbursement criteria implemented by the Plan; not all requirements apply to each product—providers should review plan documents for eligible coverage.

ApplicabilityApplies to providers submitting claims to BCBSIL and to affected plan members where product coverage permits.

DocumentationProviders must follow Plan documents to determine eligibility and applicable reimbursement rules.

Pseudohypoparathyroidism and related disorders — referenced conditions

PHPIBPseudohypoparathyroidism Type 1B — due to methylation defect at the GNAS coding sequence.

PHPIAPseudohypoparathyroidism Type 1A — due to maternal loss of function mutation at the GNAS coding sequence.

PPHPPseudopseudohypoparathyroidism — due to paternal loss of function mutation at the GNAS coding sequence.

POHProgressive Osseous Heteroplasia — due to paternal loss of function mutation at the GNAS coding sequence.

Acrodysostosis subtypesAcrodysostosis (ACRDYS1) — due to mutation in PRKAR1A; Acrodysostosis (ACRDYS2) — due to mutation in PDE4D.