CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB035

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

This BCBSNM Clinical Payment and Coding Policy governs reimbursement for laboratory testing used in the diagnosis and monitoring of inflammatory bowel disease (IBD) for members covered under BCBSNM plans; providers should review individual plan documents for product-specific applicability.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeClarified reimbursementliterature updated

Effective DateNov 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; consult plan documents for coverage determination.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity.

Document updated with literature review.

References revised and expanded.

Serologic testsnot reimbursable

Prometheus®algorithm testing

1.0version

Nov 1, 2023effective

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Coverage Criteria for IBD Laboratory Testing

Non-reimbursable IBD lab tests

Reimbursement exclusions for specific serologic markers and algorithm-based tests used for IBD diagnosis or monitoring.

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Non-reimbursable IBD lab tests

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Extracted coverage context

Policy revisions and literature citations informing coverage and reimbursement:

Policy update history: 7/5/2023 — document updated with literature review; reimbursement information revised for clarity. Prior policy effective date: 11/1/2022 (new policy).

Evidence and guidelines referenced: Multiple guideline and research references inform the policy, including NICE, ACG, ECCO and multiple diagnostic accuracy and biomarker studies (examples: Menees et al. 2015; Plevy et al.; Rubin et al.).

Coverage/Gaps note: This extract does not include detailed code-level billing rules, limits, or product-specific applicability; providers should review plan documents and other policy sections for explicit coverage criteria and billing instructions.

Coding and Procedure Guidance

Coding guidance and procedure code notemixed

No codes listed

Provider Responsibilities and Reimbursement Notes

Documentation Required

Documentation and claim review expectations

Providers must submit accurate documentation and code claims using valid HIPAA-approved code sets; claims are subject to review and providers may be asked to provide additional documentation upon request. Claim review may consider plan documents, provider contracts, medical policies, CPCPs, and code edit protocols.

Submit claims using valid HIPAA-approved code sets (e.g., CPT, HCPCS, ICD-10).
Ensure coding follows industry standard coding guidelines (UB, AMA CPT, CPT Assistant, CMS NCCI, DRG, etc.).
Be prepared to provide additional documentation when requested for claim review against plan documents, contracts, medical policies, or coding edits.

Billing Rule

Reimbursement clarification (7/5/2023)

Definitions and Plan Terms

Plan documents — applicability and precedence

DefinitionPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents that govern coverage when conflicting with this Clinical Payment and Coding Policy.

Governing ruleIf a conflict arises between a CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Provider contract precedenceIf a conflict arises between a CPCP and any provider contract, the provider contract will govern.

Applicability noteNot all requirements in this CPCP apply to each product; providers are urged to review plan documents for eligible coverage.

BCBSNM discretionary authority

Authority statement

IBD-related biomarkers (serologic and fecal)

Common inflammatory markersC-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are referenced as serologic markers used to exclude or assess IBD.

Fecal markersFecal calprotectin and fecal lactoferrin are cited as fecal biomarkers for differentiating IBD from IBS and monitoring inflammation.

IBD-related antibodiesAnti-Saccharomyces cerevisiae antibodies (ASCA) and perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) are listed among IBD antibody panels.

Additional serologic markersOther serologic markers referenced include antibody to Escherichia coli outer membrane porin C (anti-OmpC), anti-I2, anti-CBir1, ACCA, ALCA, AMCA, and PKM2 as noted in literature and diagnostic studies.