CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB016

Pediatric Preventive Screening

Defines laboratory reimbursement criteria for preventive screening tests for individuals newborn through age 18 (excluding newborn genetic disorder screening), including which screenings may be reimbursable and associated age- or risk-based conditions. Includes procedure code list and plan/version metadata applicable to BCBSNM products.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPediatric Preventive Screening

Policy CodePolicy CPCPLAB016

Change TypeRevised (7/17/2023)

Effective DateNov 1, 2023

Next Review Date

Key ActionProviders must submit claims using valid HIPAA-approved code combinations and follow industry-standard coding guidelines; maintain and provide documentation upon request and review plan documents for product-specific coverage.

POLICY UPDATE CHANGES

Document updated with literature review and reimbursement information revised for clarity on 7/17/2023.

Initial policy created 11/1/2022.

11Key listed screening types

23References cited

~22Procedure codes listed

Policy summary

BCBSNM policy CPCPLAB016 establishes laboratory reimbursement criteria for pediatric preventive screening tests for individuals from newborn through age 18 years. The policy is intended to guide reimbursement for age- and risk-based pediatric screening (e.g., newborn panels, lead, anemia, tuberculosis, dyslipidemia, sickle cell, hypothyroidism, hyperbilirubinemia) and references guideline organizations including the AAP, CDC, USPSTF, and HRSA. Coverage stance for the policy is mixed.

Policy metadata and thresholds

Policy NumberCPCPLAB016

PayerBlue Cross Blue Shield - New Mexico

Effective Date2023-11-01

Last Review2023-07-17

Next Review

age range for policy applicabilitynewborn through age 18 years

blood lead routine screening age12 months to 2 years

blood lead risk-based screening age6 months to 6 years (if at increased risk)

anemia routine screening age12 months

anemia risk-based screening age>= 4 months (if at risk)

tuberculosis screening lower age>= 1 month (if at increased risk)

dyslipidemia one-time age period listed9-11 years (once during age period)

Reimbursable pediatric preventive screening tests (criteria)

Reimbursable Pediatric Preventive Screening Tests

Tests may be reimbursable when the specified age and/or risk criteria are met:

ALL of the following

Applies to individuals newborn through age 18 years (excluding newborn screening for genetic disorders)
Newborn screening panel may be reimbursable when it follows all applicable federal and state law recommendations
Screening for hyperbilirubinemia in all newborns may be reimbursable
Screening for congenital hypothyroidism in all newborns utilizing serum thyroxine (T4) and/or thyroid-stimulating hormone (TSH) may be reimbursable
Screening for sickle cell disease in all newborns may be reimbursable
Blood lead screening
- All individuals ages 12 months to 2 years12 months to 2 years
  See Note 1
- Individuals ages 6 months to 6 years who are at increased risk for lead exposure (see Note 1)6 months to 6 years (if at increased risk)
  See Note 1
Screening for anemia with hemoglobin or hematocrit
- For all individuals 12 months of age12 months
- For individuals 4 months and older if at risk for iron deficiency (See Note 2)≥ 4 months (if at risk)
  See Note 2
For individuals 1 month of age or older who are at increased risk of contracting tuberculosis (See Note 3), tuberculosis screening may be reimbursable>= 1 month (if at increased risk)
See Note 3
Screening for dyslipidemia
- Annually for children and adolescents who are at increased risk due to personal history or family history (See Note 4)annual (if at increased risk)
  See Note 4
- Age-based once per period
  - For individuals 9 - 11 years of age9-11 years (once during period)

Scope excludes newborn genetic disorder screening; newborn screening panels may be reimbursable only when they follow applicable federal and state law recommendations. Coverage and applicability may vary by product—providers should review specific plan documents for eligible coverage (Plan-product applicability).

Billing, documentation & plan applicability

Billing Rule

Use HIPAA approved code sets and valid code combinations

Providers must submit claims for services using valid HIPAA-approved code combinations and appropriate industry-standard coding guidelines (CPT, HCPCS, ICD-10, NDC, UB, DRG, etc.).

CPT
HCPCS
ICD-10
NDC
UB
DRG

Documentation Required

Maintain and provide documentation upon request

Claims are subject to claim review; providers are urged to submit additional documentation upon request to support services billed and eligibility under plan documents.

Submit additional documentation upon request to support services billed and member eligibility under applicable plan documents.

Prior Authorization

Plan-product applicability

Not all requirements apply to each product — providers should review specific plan documents for eligible coverage for services rendered.

Not all requirements apply to each product — review specific plan documents.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPediatric Preventive Screening

Policy CodePolicy CPCPLAB016

Change TypeRevised (7/17/2023)

Effective DateNov 1, 2023

Next Review Date

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Pediatric Preventive Screening

Policy summary

Reimbursable pediatric preventive screening tests (criteria)

Procedure codes

Billing, documentation & plan applicability

Key terms

Background & evidence

Policy changes & updates