CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB016

Pediatric Preventive Screening

Defines BCBSNM reimbursement criteria for laboratory-based preventive screening tests for individuals from newborn through age 18 (excluding newborn genetic screening), and clarifies which pediatric screening tests may be reimbursable under plan documents.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPediatric Preventive Screening

Policy CodePolicy CPCPLAB016

Change TypeRevised (clarity, coding relocations, age scope)

Effective DateJan 15, 2025

Next Review Date

Key ActionReview plan-specific documents for prior authorization and eligibility because not all reimbursement requirements apply to every product.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and literature review updated.

Dyslipidemia screening for individuals ages 17-21 moved to CPCPLAB020; STI screening for adolescents moved to CPCPLAB051; Annual Hepatitis B screening moved to CPPLAB015.

This policy applies to lab-based preventive screening tests performed on individuals newborn through age 18, except newborn genetic disorder screening.

newborn–18age range covered

≥1related policies referenced

20procedure/lab codes

04/29/2024last approval

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Reimbursable Pediatric Screening Criteria

Reimbursable pediatric screening criteria

Screening tests may be reimbursable in the following situations:

Newborn screening panels: Newborn screening panel may be reimbursable when it follows all applicable federal and state law recommendations.

[[chunk 4]]

Newborn hyperbilirubinemia: Screening for hyperbilirubinemia in all newborns may be reimbursable.

[[chunk 4]]

Congenital hypothyroidism: Screening for congenital hypothyroidism in all newborns utilizing serum thyroxine (T4) and/or thyroid-stimulating hormone/TSH may be reimbursable.

[[chunk 4]]

Sickle cell disease: Screening for sickle cell disease in all newborns may be reimbursable.

[[chunk 4]]

Blood lead screening may be reimbursable for: a) individuals ages 12 months to 2 years; b) individuals ages 6 months to 6 years who are at increased risk for lead exposure.age-based and risk-based

See Note 1 for CDC lead risk factors. [[chunk 4]][[chunk 5]]

Anemia screening: Screening for anemia with hemoglobin or hematocrit determination may be reimbursable: a) for all individuals 12 months of age; b) for individuals 4 months and older who are at risk for iron deficiency.age-based and risk-based

See Note 2 for iron deficiency risk factors. [[chunk 4]][[chunk 5]]

Tuberculosis screening: For individuals 1 month of age or older who are at increased risk of contracting tuberculosis, tuberculosis screening may be reimbursable.risk-based

See Note 3 for TB risk factors. [[chunk 4]][[chunk 5]]

Dyslipidemia screening: Screening for dyslipidemia with a fasting lipid profile or a non-fasting non-HDL-C may be reimbursable: a) annually for children and adolescents who are at increased risk due to personal history or family history; b) once during each of the age periods for individuals 9-11 years of age and once for individuals 17 years of age.age-based and risk-based

See Note 4 for dyslipidemia risk factors. [[chunk 4]][[chunk 5]]

This policy specifically excludes newborn genetic disorder screening; such screening is addressed separately through federal and state newborn screening programs and is not covered under this policy.

Coverage language in this policy uses the phrase “may be reimbursable” to indicate that reimbursement is contingent on meeting the listed age- and risk-based criteria. Plan documents and member-specific benefit language determine final coverage decisions; there is no blanket coverage without applicable plan provisions and the conditions set forth in this policy.

Procedure and Laboratory Codes

Listed procedure/lab codesmixed

80061
82247
82248
82465
83020
83021
83655
83718
84439
84443

1–10 of 21

1/3

BMI percentile (definitions)

Overweight (BMI percentile)BMI ≥85th percentile and <95th percentile

Obesity (BMI percentile)BMI ≥95th percentile

Use in dyslipidemia risk assessmentOverweight and obesity percentiles are listed as AAP dyslipidemia risk factors for pediatric patients

Provider Requirements and Billing Notes

Prior Authorization

Plan-specific prior authorization — not all requirements apply to every product; providers should review plan documents for eligibility and prior auth rules

BCBSNM has implemented certain lab management reimbursement criteria. Not all requirements apply to every product; providers should review plan documents for eligibility and prior authorization rules. If a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document governs. If a conflict arises between a CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services, the provider contract governs. Plan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. Blue Cross and Blue Shield of New Mexico may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSNM has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.

Review member-specific plan documents to confirm coverage and prior authorization requirements before ordering laboratory tests.
Not all lab management reimbursement requirements apply to every product; verify product-specific rules.
Upon request, submit additional documentation to support medical necessity and billing.

Policy Background

This policy summarizes BCBSNM reimbursement criteria for laboratory-based preventive screening tests for individuals from newborn through age 18. It describes which pediatric screening tests may be reimbursable when performed in accordance with the specified age- and risk-based conditions (for example, newborn screening panels, hyperbilirubinemia, congenital hypothyroidism, sickle cell disease, lead screening, anemia screening, tuberculosis screening, and dyslipidemia screening). Newborn genetic disorder screening is excluded from this policy and is handled separately.

Key Definitions

Adolescent — definition

Adolescent (WHO definition)Any person between the age of 10 and 19 years

SourceWorld Health Organization (WHO), 2023 as cited in policy

Policy age scope contextPolicy applies to laboratory-based preventive screening tests performed on individuals newborn through age 18 (WHO adolescent definition provided for reference)

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPediatric Preventive Screening

Policy CodePolicy CPCPLAB016

Change TypeRevised (clarity, coding relocations, age scope)

Effective DateJan 15, 2025

Next Review Date

Key ActionReview plan-specific documents for prior authorization and eligibility because not all reimbursement requirements apply to every product.

SourceLink

On This Page

Documentation Required

Documentation and coding accuracy — claims subject to code edit protocols and claim review

Providers are responsible for submission of accurate documentation of services performed. Submit claims using valid code combinations from HIPAA-approved code sets and code appropriately per industry-standard coding guidelines. Claims are subject to code edit protocols and claim review, including plan coverage terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.

Use HIPAA-approved code sets: CPT, HCPCS, ICD-10-CM/PCS, NDCs, and applicable modifiers.
Follow Uniform Billing, AMA CPT guidance, CMS NCCI edits and policy manuals when coding lab services.
Claims may be denied or adjusted if coding is inaccurate or documentation is insufficient.

Note

Provider-action callout — review plan documents and age-based coverage

Providers are urged to review Plan documents for eligible coverage for services rendered and to confirm whether prior authorization is required for specific laboratory tests. This policy refers to laboratory-based preventive screening tests performed on individuals newborn through age 18 years (WHO defines adolescent as ages 10–19).

Confirm age-based coverage rules for preventive screening tests (newborn through 18 years).
Verify whether newborn genetic disorder screening is covered under separate newborn screening provisions.

Documentation Required

Required documentation — providers must submit accurate documentation and valid code combinations

Providers are expected to retain and provide, upon request, accurate supporting documentation for billed services. Documentation should demonstrate medical necessity, date(s) of service, results if applicable, and linkage to billed CPT/HCPCS/ICD-10 codes.

Include clinical rationale and test results when submitting claims for review.
Maintain records consistent with federal and state regulations and BCBSNM request timelines.