Urinary Tumor Markers for Bladder Cancer
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Defines BCBSNM reimbursement stance for urinary tumor marker tests for bladder cancer diagnosis and surveillance, and identifies specific situations where tests are reimbursable or not; applies to providers submitting claims to Blue Cross Blue Shield - New Mexico.
Reimbursement Information #1 and #2 were edited for clarity.
References were revised during the most recent update.
Several CPT/HCPCS codes (0012M, 0013M, 0363U, 0420U, 0452U, 0465U, 0549U) were removed in a prior update.
Coverage Criteria for Urinary Tumor Markers
Reimbursement criteria
Covered when ALL of the following criteria are met:
ONE of
ALL of the following
ONE of
- Diagnostic exclusion of bladder cancer for individuals with atypical or equivocal cytology.
- Monitoring of high-risk, non-muscle invasive bladder cancer.
- Adjunct to cystoscopy or urinary cytology: fluorescence immunocytology (ImmunoCyt/uCyt) may be reimbursed when used for monitoring individuals with bladder cancer.
Procedure Codes
| 86294 | IMMUNOASSAY TUMOR QUAL. |
| 86316 | IMMUNOASSAY TUMOR OTHER. |
| 86386 | NUCLEAR MATRIX PROTEIN 22. |
| 88120 | CYTP URNE 3-5 PROBES EA SPEC |
| 88121 | CYTP URINE 3-5 PROBES CMPTR. |
| 88346 | IMFLUOR 1ST 1ANTB STAIN PX. |
| 88350 | IMFLUOR EA ADDL 1ANTB STN PX. |
| 0365U | ONC BLDR 10 UR HRBR URTHL CA. |
| 0366U | ONC BLDR 10 PRB RECR BLDR CA. |
| 0367U | ONC BLDR 10 FLWG TRURL RESCJ |
| No codes listed |
Documentation, Claims, and Plan Eligibility
Documentation and claim submission requirements
Providers must submit accurate documentation of services performed and submit claims using valid HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD-10) per industry coding guidelines; claims are subject to code edit protocols and may be reviewed and audited, and providers may be asked to submit additional documentation upon request.
- Submit claims using valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD-10, etc.).
- Code claims appropriately per industry standard coding guidelines and CCI/CM S rules.
- Be prepared to provide additional documentation if requested during claim review or audit.
Verify plan‑specific eligibility before billing
Not all lab management reimbursement requirements in this policy apply to every product; providers must review the member's individual Plan documents (Certificates, Benefit Booklets, Summary Plan Descriptions, provider contracts) to determine eligible coverage for services rendered.
- If a conflict exists between this reimbursement policy and a Plan document, the Plan document governs.
- Provider contracts may supersede policy language where applicable—verify contract terms for coverage.
- Review Plan documents to confirm whether specific urinary tumor marker tests are covered for the member prior to billing.
Key Definitions and Clinical Scenarios
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