ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLABO2O

Cardiovascular Disease Risk Assessment

Defines Blue Cross Blue Shield of New Mexico reimbursement policy for laboratory testing used in cardiovascular disease (CVD) risk assessment for members and providers, including which tests are reimbursable, frequencies, and tests considered not reimbursable.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCardiovascular Disease Risk Assessment

Policy CodePolicy CPCPLABO2O

Change TypeCoding and frequency updates

Effective DateOct 30, 2024

Next Review Date

Key ActionSubmit claims with accurate documentation and appropriate HIPAA-approved codes; note CPT code 84512 was added and 04223T removed.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information revised 1.a.i to specify every 4 years for individuals ages 18 to 79 years.

Added an annual frequency option to item 1.d.

Added CPT code 84512 and removed code 04223T from the policy coding list.

Lipid panel screening frequency was clarified to allow annual screening for those with increased risk of dyslipidemia.

4 yearsroutine interval (18–79)

annualincreased-risk frequency

18+adult age threshold

10/30/2024

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Coverage criteria for CVD risk assessment laboratory testing

CVD laboratory coverage criteria

Reimbursement and non-reimbursement criteria for laboratory tests used in CVD risk assessment for adults (18+).

ALL of the following

Screening interval
- To screen for cardiovascular disease (CVD) — every 4 years for individuals ages 18 to 79 years.
- Annually for individuals at increased risk of dyslipidemia (examples include obesity or metabolic syndrome; hypothyroidism; nephrotic syndrome; hyperthyroidism; pancreatitis; diabetes; Cushing syndrome; chronic kidney disease; pregnancy; cholestatic liver disease; lipid metabolism disorders such as Gaucher disease).
To establish baseline levels before initiating statin therapy.
For individuals who are about to begin or who are currently receiving statin therapy: every 4 to 12 weeks after initiation or change of therapy.
Annually for individuals on a long-term therapy that requires lipid monitoring (for example, isotretinoin, certain antipsychotics); annually when no medication changes have occurred.

ALL of the following

To establish baseline levels before initiating ART.
Every 1 to 3 months after initiation or change of therapy.
Every 6 to 12 months when no medication changes have occurred.

ANY of the following

Individuals with hypertriglyceridemia.
Individuals with diabetes mellitus.
Individuals with obesity or metabolic syndrome.
Individuals who are on lipid therapy.
Individuals with other dyslipidemias (such as very low LDL-C).
Individuals suspected to have familial dysbetalipoproteinemia or familial combined hyperlipidemia.

Lipoprotein(a) (Lp[a]) measurement is not reimbursable as an adjunct to LDL cholesterol in the risk assessment and management of cardiovascular disease.

ALL of the following

Initial screening requires two measurements at least 2 weeks apart.
If the initial screen was abnormal, follow-up screening is allowed up to once per year.

ALL of the following

High-sensitivity cardiac troponin (hs-cTnT).
Homocysteine testing (for CVD risk assessment, screening, evaluation, and management).
Novel lipid and non-lipid biomarkers (for example apolipoprotein A1, apolipoprotein E, B-type natriuretic peptide, cystatin C, fibrinogen, leptin, LDL/HDL subclasses).
Lipoprotein-associated phospholipase A2 (Lp-PLA2) and secretory type II phospholipase A2 (SPLA2-IIA).
Serum intermediate density lipoproteins.
Long-chain omega-3 fatty acids in red blood cell membranes.

Note: A simple lipid panel is generally composed of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides; certain calculated ratios (such as total/HDL) may also be reported. Other tests (apolipoproteins, particle number/size, Lp[a], etc.) are not considered components of a simple lipid panel.

Clinicians may individualize PCE-based risk assessment using risk-enhancing factors such as primary hypercholesterolemia, family history of premature ASCVD, metabolic syndrome, chronic inflammatory conditions, chronic kidney disease, pregnancy-associated conditions, certain biomarker thresholds (e.g., elevated Lp(a), apoB, hsCRP), and ABI < 0.9.

If conflicts arise between this policy and plan documents or provider contracts, the plan document or provider contract governs; BCBSNM retains discretionary authority as provided under plan documents.

Coverage criteria and coding changes

Reimbursement Information updates (excerpted):

Routine lipid risk assessment: every 4 years for individuals ages 18-79.

Lipid panel for individuals at increased risk of dyslipidemia: annual screening allowed.

Coding change: CPT code 84512 added to the policy coding list.

Coding change: Code 04223T removed from the policy coding list.

Procedure codes, coding guidance, and frequency highlights

Example procedure codes referencedCPT

80061	Lipid panel
82465	Lipoprotein, direct measurement
83700	Lipoprotein, direct measurement (alternate)
0052U	Proprietary/other molecular or protein biomarkers (example listed)

Policy coding changesCPT

84512	Added to policy coding list (specific test not named in this fragment)
04223T	Removed from policy coding list

inv-05: Routine lipid screening interval (ages 18–79) — every 4 years.

IntervalEvery 4 years for individuals ages 18–79

PopulationAdults 18 years of age and older (routine guidance applies specifically to ages 18–79)

Policy changeReimbursement Information revised to specify every 4 years for individuals ages 18 to 79 years (effective 10/30/2024)

inv-06: routine_screening_interval — every 4 years for ages 18-79 (dup of routine interval, preserved as separate inventory item).

routine_screening_intervalEvery 4 years for individuals ages 18–79

ContextApplied as the routine screening frequency for lipid testing to assess CVD risk

Documentation, claims submission, and provider notices

Documentation Required

Documentation and claims submission

Providers are responsible for submission of accurate documentation of services performed. Submit claims using valid HIPAA-approved code sets and appropriate industry-standard coding guidelines (for example: Uniform Billing Editor, AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI policy manual, and CCI table edits). Claims are subject to review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers must supply additional clinical or administrative documentation to support the claim.

Use valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.)
Code claims per industry-standard coding guidelines and CMS edits
Claims may be reviewed and requests for additional documentation may be made

Billing Rule

Definitions and reference concepts

inv-10: Simple lipid panel — definition and component breakdown.

DefinitionSimple lipid panel: a core lipid profile composed of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides

Calculated valuesCertain calculated ratios (e.g., total/HDL cholesterol) may also be reported as part of a simple lipid panel

Not includedApolipoproteins, lipid particle number/size, lipoprotein(a), and other advanced biomarkers are not considered components of a simple lipid panel

inv-11: Pooled Cohort Equations (PCEs) — description of the ACC/AHA 2013 risk calculator and its role in testing decisions.

What it isPooled Cohort Equations (PCEs): the 2013 ACC/AHA risk calculator used to estimate 10-year risk of ASCVD/CVD events

Role in testing decisions

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCardiovascular Disease Risk Assessment

Policy CodePolicy CPCPLABO2O

Change TypeCoding and frequency updates

Effective DateOct 30, 2024

Next Review Date

Key ActionSubmit claims with accurate documentation and appropriate HIPAA-approved codes; note CPT code 84512 was added and 04223T removed.

SourceLink

On This Page

Multi-marker CVD panels other than simple lipid panels.

Effective updateDocument update (10/30/2024) added this explicit interval to reimbursement information

inv-07: increased_risk_screening_interval — annual screening allowed for individuals at increased risk or on long-term lipid-monitoring therapy.

IntervalAnnual screening allowed for individuals at increased risk of dyslipidemia or when on long-term lipid-monitoring therapy

Examples of increased riskIncreased CVD risk per 2013 ACC/AHA Pooled Cohort Equations, obesity/metabolic syndrome, diabetes, chronic kidney disease, pregnancy, lipid disorders, hypothyroidism, nephrotic syndrome, pancreatitis, Cushing syndrome

Long-term therapy exampleAnnual monitoring allowed for individuals on long-term therapies that require lipid monitoring (e.g., isotretinoin, certain antipsychotics)

Reimbursement / coding update

This policy was revised effective 2024-10-30 to update reimbursement/coding information. CPT code 84512 was added to the policy and code 04223T was removed. Reimbursement information and frequency specifications were revised (for example: revised interval for screening to every 4 years for ages 18–79 in 1.a.i and added annual frequency to 1.d); references were updated. Providers should bill using the current, policy-specified codes and frequencies and follow payer billing guidance for reimbursement.

Added CPT code 84512
Removed code 04223T
Revised reimbursement frequencies (e.g., every 4 years for ages 18–79 in 1.a.i; added "annually" to 1.d)
References updated

PCEs are used to define increased cardiovascular risk and to inform frequency of lipid screening and clinician-patient risk discussions

Limitation and useGuidance notes the PCE predicts population risk but may be individualized with additional risk-enhancing factors during clinician–patient discussions

inv-12: Citations and guideline sources for risk assessment — references used to support policy recommendations.

Primary guideline reference2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (PCE) referenced in policy notes

Supporting literatureMultiple references and literature cited in the policy update history and references section (examples include Lipids Health Dis; J Atheroscler Thromb; Jaffe A. on troponin testing)

Policy update recordReferences were updated as part of the 10/30/2024 policy revision