Pancreatic Enzyme Testing for Acute Pancreatitis
Customize your policy alerts
Sign up for Blue Cross Blue Shield - New Mexico Policy RPLAB047 alerts
Get alerted when Policy RPLAB047 changes without checking for updates manually.
Monitor payer policy activity
Defines when laboratory measurement of pancreatic enzymes and related biomarkers for suspected acute pancreatitis are eligible for reimbursement by BCBSNM and which tests are not reimbursable; applies to providers submitting claims to BCBSNM.
Added to #1 '(no more than one test per day in the outpatient setting).'
Removed #2.
New #2 (formerly #3) removed the word 'serum' to clarify measurement of amylase from pancreatic cyst fluid.
Removed #6 as other types of amylase testing are not reimbursable and were consolidated into new #2.
Added code 86141.
Measurement of amylase is no longer allowed for the diagnosis of acute pancreatitis (removed from #1 and #2 on 07/25/2025).
When ordered for anything other than analysis of pancreatic cyst fluid, measurement of serum amylase is not reimbursable.
Edited #2 to clarify non-reimbursement of serum lipase or amylase for individuals already diagnosed with acute or chronic pancreatitis.
Added #6: For all other situations or conditions not described above, measurement of serum lipase and/or amylase is not reimbursable.
Coverage and Reimbursement Criteria
Coverage criteria for pancreatic enzyme testing
Covered when ALL of the following are met:
ALL of the following
ONE of
- Measurement of serum lipase may be reimbursable for individuals presenting with signs and symptoms of acute pancreatitis (see Note 1). In the outpatient setting, reimbursed serum lipase is limited to no more than one test per day.
- Measurement of amylase is not reimbursable when ordered for anything other than analysis of pancreatic cyst fluid.
- For diagnosis, assessment, prognosis, and/or determination of severity of acute pancreatitis, measurement of serum and urine trypsin/trypsinogen/TAP (trypsinogen activation peptide) is not reimbursable.
- For diagnosis, assessment, prognosis, and/or determination of severity of acute pancreatitis, measurement of the following biomarkers is not reimbursable: C-reactive protein (CRP); Interleukin-6 (IL-6); Interleukin-8 (IL-8); Procalcitonin.
- Measurement of serum lipase for all other situations or conditions not described above is not reimbursable.
Reimbursement criteria (policy revisions and current reimbursement rules)
Reimbursement rules and recent operational clarifications (policy history highlights):
Procedure Codes and Coding Notes
| 86141 | Added to policy coding list (C-REACTIVE PROTEIN HS) |
Documentation, Billing, and Authorization Guidance
Documentation, coding, and reimbursable conditions — submit accurate claims and expect review
Providers must submit accurate documentation of services performed and code claims using valid HIPAA-approved code sets; claims are subject to code edit protocols and review against plan documents, provider contracts, medical and reimbursement policies, and coding guidelines. Serum lipase may be reimbursable for individuals presenting with signs and symptoms of acute pancreatitis, but outpatient reimbursement is limited to no more than one test per day; other listed tests (trypsin/trypsinogen/TAP, CRP, IL-6, IL-8, procalcitonin) and most amylase testing are not reimbursable except as noted for pancreatic cyst fluid analysis.
- Submit claims using valid code combinations from HIPAA-approved code sets and follow industry coding guidelines (e.g., CPT, HCPCS, ICD-10-CM).
- Claims are subject to code edit protocols and may be reviewed against Plan documents, provider contracts, medical and reimbursement policies; provide additional documentation upon request.
- Serum lipase: reimbursable for symptomatic acute pancreatitis (outpatient limit: one test per day).
- Amylase: not reimbursable when ordered for anything other than pancreatic cyst fluid analysis.
- Do not submit claims for trypsin/trypsinogen/TAP or listed biomarkers for diagnosis/assessment/prognosis/severity of acute pancreatitis (these are non-reimbursable).
Prior authorization / billing: add 86141; outpatient frequency and amylase exception
Add CPT code 86141 to the policy coding list where applicable; outpatient pancreatic enzyme testing reimbursement is limited to no more than one test per day. Measurement of serum amylase is not reimbursable except when performed on pancreatic cyst fluid, and serum lipase/amylase testing for monitoring in already-diagnosed acute or chronic pancreatitis is non-reimbursable.
- Policy history: code 86141 was added to the coding list (see Policy History).
- Outpatient testing frequency limit: no more than one pancreatic enzyme test per day for outpatient reimbursement.
- Amylase exception: amylase measurement may be reimbursable only for analysis of pancreatic cyst fluid; serum amylase otherwise not reimbursable.
- Monitoring exclusion: serum lipase or amylase for individuals already diagnosed with acute or chronic pancreatitis is non-reimbursable.
Definitions and Clinical Context
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.