CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO71

Colorectal Cancer Screening

This policy defines Blue Cross Blue Shield of New Mexico's reimbursement stance and criteria for colorectal cancer screening tests and which tests are reimbursable for covered members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyColorectal Cancer Screening

Policy CodePolicy CPCPLABO71

Change TypeRevised (modality listings) + Clarified (literature review)

Effective DateJan 15, 2025

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and valid HIPAA-approved code combinations; follow plan documents and coding edits.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information was revised to remove direct visualization tests (colonoscopy, CT, flexible sigmoidoscopy) from #1 and removed colon capsule endoscopy from #4.

Document updated with literature review.

45-75age range for reimbursable annual FIT/gFOBT screening

Every 3 yrsscreening interval for FIT-DNA

Over 75not reimbursable (age)

Septin 9not reimbursable (blood test)

Anal cytology/HPV

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Reimbursable and Non‑Reimbursable Colorectal Cancer Screening

Reimbursable and non-reimbursable colorectal cancer screening

Reimbursement stance for colorectal cancer screening tests for asymptomatic, average‑risk individuals:

ALL of the following

Fecal immunochemical test (FIT) — annual
Guaiac fecal occult blood test (gFOBT) — annual
Multitarget stool DNA (FIT‑DNA, e.g., Cologuard) — once every 3 years

ALL of the following

Methylated Septin 9 (ColoVantage) — not reimbursable for colorectal cancer screening
Colorectal cancer screening for average‑risk, asymptomatic individuals over 75 years of age — not reimbursable
ANY of the following
- Screening for anal cytologic abnormalities (anal Pap smear)
- Screening for anal HPV infection

Procedure Codes and Age-Based Coverage Thresholds

Procedure codes guidancemixed

Procedure codes listed in policy (not exhaustive); inclusion does not guarantee coverage.

Age-based coverage threshold

Reimbursable age rangeAsymptomatic individuals 45-75 years — annual FIT or gFOBT may be reimbursable

Not reimbursable — older than thresholdAverage-risk, asymptomatic individuals over 75 years — colorectal cancer screening is not reimbursable

FIT-DNA intervalFIT-DNA (Cologuard) may be reimbursable once every 3 years

Claims Submission and Documentation Requirements

Documentation Required

Claims submission, documentation and plan document applicability

Providers must submit accurate documentation of services performed and submit claims using valid HIPAA‑approved code sets and appropriate code combinations. Claims are subject to plan documents, provider contracts, this policy, coding edits and claim review; BCBSNM may interpret and apply this policy with discretion and may request additional documentation upon review.

Submit claims using valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, etc.).
Code claims according to industry standard coding guidelines (Uniform Billing, AMA CPT, CMS NCCI, CCI edits).
Claims are subject to plan documents and provider contracts which govern in case of conflict.
BCBSNM may request additional documentation and exercises discretionary interpretation and application of this policy.

Lab Management Reimbursement Criteria

Lab management reimbursement criteria

DefinitionLab management reimbursement criteria: BCBSNM has implemented certain lab management reimbursement criteria; not all requirements apply to each product — providers should review plan documents for eligible coverage

Applicability noteRequirements may vary by product — providers are urged to review Plan documents for coverage eligibility

Relation to claimsClaims for services are subject to plan documents, provider contracts, policy and coding edits and BCBSNM may interpret and apply the policy with discretion