CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO26

Fecal Calprotectin Testing in Adults

This document defines Blue Cross Blue Shield of New Mexico's reimbursement stance and lab management criteria for fecal calprotectin testing in adults and informs providers about when testing may be reimbursable under BCBSNM plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyFecal Calprotectin Testing in Adults

Policy CodePolicy CPCPLABO26

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and coding; claims are subject to review and additional documentation may be requested.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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Fecal Calprotectin Testing Coverage Criteria

Fecal calprotectin testing coverage criteria

BCBSNM reimbursement positions for fecal calprotectin testing:

Reimbursable when evaluating a differential diagnosis between non-inflammatory gastrointestinal disease (e.g., irritable bowel syndrome) and inflammatory disease

Clinical indication for differential diagnostic evaluation should be present in the claim or documentation.

Reimbursable for monitoring gastrointestinal conditions such as inflammatory bowel disease (IBD) to assess response to therapy and relapse

Documentation should indicate monitoring of IBD, assessment of therapy response, or evaluation for relapse.

Not reimbursable for indications other than those explicitly listed above

Claims for other indications will be denied or not reimbursed per policy.

Coding Guidance

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyFecal Calprotectin Testing in Adults

Policy CodePolicy CPCPLABO26

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and coding; claims are subject to review and additional documentation may be requested.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Documentation and Claims Submission Responsibility

Documentation Required

Documentation and Claims Submission Responsibility

Providers are responsible for submission of accurate documentation of services performed and for coding claims using valid HIPAA-approved code sets. Claims should be coded appropriately according to industry standard coding guidelines, including but not limited to: UB editor, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG guidelines, CMS NCCI Policy Manual, CCI table edits and other CMS guidelines. Claims are subject to code edit protocols and review against plan documents, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers must furnish additional documentation to support the claim. If a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern; if a conflict arises between this policy and any provider contract, the provider contract will govern. BCBSNM may use reasonable discretion in interpreting and applying this policy and has final discretionary authority to the extent provided under applicable plan documents.

Use HIPAA-approved code sets and valid code combinations
Follow industry coding guidelines (UB, AMA CPT, CPT Assistant, HCPCS, ICD-10, NDC, DRG, CMS NCCI/CCI)
Claims subject to code edit protocols and review against plan documents, contracts, and policies
Provide additional documentation upon request to support claims
Plan documents or provider contracts govern in case of conflict; BCBSNM discretion applies

Lab Management Reimbursement Criteria — Definitions

Lab management reimbursement criteria — definition and key points

DefinitionPayer-established rules governing when laboratory tests will be reimbursed under BCBSNM products; applicability varies by product.

ScopeApplies to specific lab tests (e.g., fecal calprotectin) where BCBSNM has defined reimbursement positions; not all requirements apply to every product.

Provider responsibilityProviders are urged to review plan documents to determine eligible coverage for services rendered.

Effect on claimsClaims will be reviewed against plan documents, contracts, medical policies, and coding edits; additional documentation may be requested.

Policy referenceSee BCBSNM lab management reimbursement criteria for test-specific coverage criteria and evidence requirements.