CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO46

Biomarkers for Myocardial Infarction and Chronic Heart Failure

Reimbursement and coding criteria governing laboratory biomarker testing for suspected acute coronary syndrome/myocardial infarction and chronic heart failure for BCBSNM products; applies to providers submitting claims to Blue Cross Blue Shield New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyBiomarkers for Myocardial Infarction and Chronic Heart Failure

Policy CodePolicy CPCPLABO46

Change TypeMaterial additions and language clarifications

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit accurate documentation and use HIPAA-approved code sets; claims may be subject to review and require additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Qualitative measurement of cardiac troponin (troponin T or I) is not reimbursable for all situations.

For all situations in the outpatient setting, analysis of ST2 and/or its isoforms (e.g., Presage ST2) is not reimbursable.

Reimbursement Information was updated following literature review (policy language clarified and title/reference updates).

up to 4Allowable quantitative troponin measurements within first 72 hours for outpatient capable of adequate MI evaluation

multiple excludedListed cardiac biomarkers not reimbursable for MI diagnosis/prognosis

14Procedure/CPT/other codes listed (not exhaustive)

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Reimbursement Criteria

Reimbursement Information

Covered when ALL of the following apply:

ALL of the following

ALL of the following
- ALL of the following
  - ALL of the following
    Up to 4 measurements within the first 72 hours following initial presentation
    Reimbursement limited to up to four quantitative troponin measurements in the first 72 hours

Not reimbursable (deny)

Qualitative measurement of cardiac troponin (troponin T or I)
Qualitative troponin is not reimbursable for any situation
Measurement of the following biomarkers for diagnosis and/or prognosis of MI: Aspartate aminotransferase (AST/SGOT), Cardiac creatine kinase MB (CK-MB), Creatine kinase (CK), Creatine kinase isoenzymes, Lactate dehydrogenase (LD/LDH), Myoglobin
Measurement of cardiac biomarkers in outpatient settings not capable of performing adequate clinical MI evaluation (e.g., independent lab or physician office)
Measurement of the following biomarkers for diagnosis and/or prognosis of MI: Copeptin, Troponin C, C-reactive protein, Heart-type fatty acid binding protein (H-FABP), and other cardiac biomarkers not listed
Analysis of ST2 and its isoforms (e.g., Presage ST2) in all outpatient situations
ST2 and its isoforms are not reimbursable in any outpatient situation

Procedure and Billing Codes

Listed biomarker procedure codes (not exhaustive)mixed

82550
82552
82553
82554
82725
83006
83615
83625
83874
84450

1–10 of 15

1/2

Listed biomarker procedure codes (not exhaustive) - grouping notemixed

No codes listed

Troponin measurement limits

Reimbursement limitQuantitative cardiac troponin (troponin T or I) may be reimbursed up to 4 measurements within the first 72 hours when tested at an outpatient facility capable of performing an adequate clinical MI evaluation.

Qualitative troponinQualitative measurement of cardiac troponin (troponin T or I) is not reimbursable in any situation.

Setting restrictionTroponin testing is reimbursable only when performed at an outpatient facility capable of adequate clinical MI evaluation; testing in independent labs or physician offices not capable of such evaluation is not reimbursable.

Documentation and Claims Requirements

Documentation Required

Documentation, Coding, and Claim Review Requirements

Providers must submit accurate documentation of services performed and submit claims using valid code combinations from HIPAA‑approved code sets. Claims are subject to code edit protocols and claim review and may require additional documentation upon request.

Use HIPAA‑approved code sets and industry standard coding guidelines (UB, AMA CPT, HCPCS, ICD‑10, NDC, DRG, CMS NCCI/CCI edits).
Be prepared to provide additional documentation when requested as part of claim review.

Key Terms and Coding Standards

ACS/MI signs and symptoms

Typical ischemic chest pain patternsIschemic chest pain with radiation to an upper extremity or both arms, often associated with diaphoresis, nausea, and vomiting.

Radiation sitesPain may radiate to upper abdomen (epigastrium), shoulders, arms, wrist, fingers, neck, throat, lower jaw and teeth (not upper jaw), and the back (interscapular region).

Quality of painDescriptions include squeezing, tightness, pressure, constriction, crushing, burning, fullness, band-like sensation, knot in center of chest, lump in throat, ache, or heavy weight on chest.

Associated autonomic and GI symptomsShortness of breath, belching, nausea, indigestion, vomiting, diaphoresis, dizziness, lightheadedness, clamminess, and fatigue.

Atypical presentationsDyspnea alone, weakness, palpitations, syncope, epigastric pain or discomfort, nausea/vomiting, or cardiac arrest.