CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO56

Gamma-glutamyl Transferase (GGT) testing

Defines Blue Cross Blue Shield New Mexico reimbursement and lab management criteria for serum gamma-glutamyl transferase (GGT) testing for adults and specifies non-reimbursable routine screening in asymptomatic individuals.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyGamma-glutamyl Transferase (GGT) testing

Policy CodePolicy CPCPLABO56

Change TypeOperational and reference updates

Effective DateSeptember 1, 2023

Next Review Date

Key ActionProviders should review plan documents for product-specific coverage and submit accurate clinical documentation to support GGT testing requests.

SourceLink

POLICY UPDATE CHANGES

Frequency limits (testing no more than once every two weeks) were added to reimbursement criteria for certain indications and to elevated alkaline phosphatase context.

Document updated with literature review and reference revisions.

Policy record created (new policy as of 11/1/2022).

>=18age threshold

every 2 weeksmax frequency

1policy version

7/17/2023committee approval

Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyGamma-glutamyl Transferase (GGT) testing

Policy CodePolicy CPCPLABO56

Change TypeOperational and reference updates

Effective DateSeptember 1, 2023

Next Review Date

Key ActionProviders should review plan documents for product-specific coverage and submit accurate clinical documentation to support GGT testing requests.

SourceLink

On This Page

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Reimbursable Indications

Covered when ALL of the following are met

Adult age requirement: Individual is 18 years of age or older.age >=18

Indication or assessment requirement: Serum GGT testing is ordered for one of the reimbursable indications below or for evaluation of elevated alkaline phosphatase (see related criteria).

Frequency limit: Serum GGT testing is performed no more than once every two weeks when indicated.frequency <= once every 2 weeks

Serum gamma‑glutamyl transferase (GGT) testing for asymptomatic individuals performed during a wellness visit or general examination without abnormal findings is not reimbursable.

Routine screening measurement of serum GGT in asymptomatic persons during wellness visits or general exams when there are no abnormal clinical or laboratory findings is considered not reimbursable under this policy.

Covered Indications

Evaluation in adults (>=18) with elevated alkaline phosphatase.

Covered when ALL of the following are met

Age: Individual is 18 years of age or older.age >=18

Clinical finding: Elevated alkaline phosphatase activity documented.

Frequency: Serum GGT testing is limited to no more than once every two weeks when performed for evaluation of elevated alkaline phosphatase.frequency <= once every 2 weeks

Assessment of liver injury, function, and/or disease in adults with at least one of the listed clinical conditions

Covered when ALL of the following are met

Age: Individual is 18 years of age or older.age >=18

Clinical indications (one or more required)

a: Chronic alcohol use.
b: Long-term drug therapy known to have a potential for causing liver toxicity.
c: Exposure to hepatotoxins.
d: Primary or secondary malignant neoplasms.

Frequency Limits

inv-15: Serum GGT — No more than once every two weeks

TestSerum gamma-glutamyl transferase (GGT)

Frequency limitNo more than once every two weeks (per policy: testing limited to once every 2 weeks when indicated)

Applicable populationIndividuals 18 years of age or older

ContextUsed to evaluate liver injury, biliary disease, alcohol use, and other hepatic/metabolic conditions

inv-12: Testing frequency — reimbursable testing frequency note (no more than once every two weeks when indicated).

Reimbursable frequency noteSerum GGT testing is reimbursable no more than once every two weeks when indicated

ScopeApplies to indicated clinical uses such as evaluation of elevated alkaline phosphatase and assessment of liver injury/disease

Not for routine screeningRoutine screening in asymptomatic individuals during wellness visits or general exams without abnormal findings is not reimbursable

Policy changeFrequency limits were added to reimbursement criteria (7/17/2023 update)

Provider Actions

Note

Plan-specific coverage review

Not all plan products have the same requirements. Providers should review member plan documents (Certificates, benefit booklets, Summary Plan Descriptions, provider contracts, etc.) for eligible coverage and specific benefit terms. BCBSNM may apply reasonable discretion when interpreting and applying this policy to services in a particular case.

Plan documents govern when there is a conflict with this policy or a provider contract.
Providers are urged to verify product-specific requirements before ordering or billing services.

Denial Risk

Asymptomatic screening not reimbursable

Claims for serum GGT testing for asymptomatic individuals during a wellness visit or general exam without abnormal findings are not reimbursable. Order and bill GGT testing for asymptomatic screening only when clinical documentation supports medical necessity per the plan's coverage criteria.

Do not bill GGT for general wellness visits or routine screening without documented abnormal findings.
For reimbursable GGT testing, ensure documentation supports one of the medical indications listed in the policy (e.g., elevated alkaline phosphatase, chronic alcohol use, hepatotoxic drug therapy, viral hepatitis, post–liver transplant assessment, etc.).

Billing Rule

Coding and claims requirements

Providers are responsible for submission of accurate documentation and for using valid code combinations from HIPAA-approved code sets. Claims may be denied if coding does not follow industry-standard coding guidelines or applicable code edit protocols.

Use appropriate coding systems and guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI/CCI edits, UB, AMA guidance).
Inclusion of a code in the fee schedule does not guarantee coverage or payment.
Claims are subject to review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.
Upon request, submit supporting clinical documentation to justify services and coding.

Documentation Required

Clinical documentation and provider responsibilities

Providers are expected to submit claims for services rendered using valid code combinations and to respond to requests for additional documentation to support services and coding. Failure to provide adequate documentation may result in claim denial or recoupment.

Maintain and provide clinical records that support the medical necessity of billed services.
Be prepared to provide additional documentation upon BCBSNM request to facilitate claims adjudication.

Ordering Requirements

Step Therapy

Ordering requirements — confirm product coverage and follow standard coding/documentation

Providers should review plan documents for product-specific coverage applicable to the ordering provider and follow standard coding and documentation practices; this policy does not mandate a specific ordering provider type or universal prior authorization.

Confirm product-level coverage rules before ordering GGT testing.
Use appropriate codes and retain documentation supporting medical necessity.

OpenPayer

Gamma-glutamyl Transferase (GGT) testing

Coverage Criteria

Covered Indications

Frequency Limits

Coding

Provider Actions

Ordering Requirements

Not Covered

Background