CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO58

Venous and Arterial Thrombosis Risk Testing (laboratory reimbursement)

Reimbursement criteria and coding guidance for laboratory testing related to venous and arterial thrombosis risk (eg, protein C, protein S, antithrombin III, Factor V Leiden/prothrombin genetic testing) for members of Blue Cross and Blue Shield of New Mexico; applies to providers submitting claims for these tests under BCBSNM plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyVenous and Arterial Thrombosis Risk Testing (laboratory reimbursement)

Policy CodePolicy CPCPLABO58

Change TypeMinor revisions and literature reviewprior material additions include exclusion of aPC assays and inclusion of PE in specific context

Effective DateAug 8, 2025

Next Review DateN/A

Key ActionSubmit claims with accurate documentation using valid HIPAA-approved code sets; BCBSNM may request supporting documentation and applies claim review protocols.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review and minor revisions to Reimbursement Information for clarity; no change to intent of reimbursement information.

Added pulmonary embolism to reimbursement statement for warfarin-induced skin necrosis/neonatal purpura fulminans context.

Added policy statement that all activated protein C (aPC) resistance assays are not reimbursable.

Policy created as a new lab management reimbursement policy.

3Named plasma assays

7Procedure codes listed

6+Reimbursable scenarios

CPCPLABO58Document ID

Reimbursement Criteria for Thrombosis Risk Testing

inv-01: Reimbursement criteria and exclusions for thrombosis risk testing

Covered when ALL of the following nested criteria are met as specified below:

Plasma testing for Protein C, Protein S, and Antithrombin III is considered for reimbursement only in the clinical scenarios and exclusions listed below.

Reimbursable clinical indications (ANY of):

Individuals less than 50 years of age who have experienced deep venous thrombosis (DVT) or pulmonary embolism (PE).
Individuals who have experienced a DVT in unusual sites (for example hepatic, mesenteric, or cerebral veins).
Individuals who have experienced a DVT and who have a strong family history of thrombotic disease.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyVenous and Arterial Thrombosis Risk Testing (laboratory reimbursement)

Policy CodePolicy CPCPLABO58

Change TypeMinor revisions and literature reviewprior material additions include exclusion of aPC assays and inclusion of PE in specific context

Effective DateAug 8, 2025

Next Review DateN/A

Key ActionSubmit claims with accurate documentation using valid HIPAA-approved code sets; BCBSNM may request supporting documentation and applies claim review protocols.

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, Billing, and Denial-Risk Rules

Documentation Required

Provider documentation and claims submission — requirements for documentation, valid HIPAA codes, and BCBSNM request for additional records

Providers must submit accurate documentation and use valid HIPAA-approved code sets when billing. BCBSNM may request additional records to validate services. Claims are subject to review against benefit coverage, provider contract terms, medical and coding policies, and automated code-edit logic; submit supporting documentation upon request.

Use industry-standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI edits).
BCBSNM may request additional medical records to adjudicate claims.

Billing Rule

Reimbursement conditions and timing — reminder that plasma testing is reimbursable only in specified scenarios and timing requirements

Plasma testing for protein C deficiency, protein S deficiency, and antithrombin III deficiency may be reimbursable only in the specified clinical scenarios and must follow timing requirements. Testing should be performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants. Assays of clotting inhibitor amount and function should be done prior to any molecular testing.

Reimbursable scenarios include: individuals <50 with DVT/PE; DVT in unusual sites; strong family history of thrombosis; first- and second-degree relatives of individuals with DVT before age 50; pregnancy or oral contraceptive-associated DVT; women <50 who smoke and had MI; pediatric arterial ischemic stroke; targeted testing before starting oral contraceptives when personal or family history of DVT exists.
Warfarin-induced skin necrosis and neonatal purpura fulminans: plasma testing for protein C and protein S deficiency may be reimbursable.
Venous thrombosis risk testing for superficial venous thrombosis (including superficial thrombophlebitis and varicosities) is not reimbursable.
DVT risk testing as part of a pre-transplant evaluation is not reimbursable.

Denial Risk

Denial-risk billing rule for aPC assays — activated protein C (aPC) resistance assays are not reimbursable

Activated protein C (aPC) resistance assays are not reimbursable under any circumstance.

All activated protein C (aPC) resistance assay testing is excluded from reimbursement.

Key Definitions

Plan documents — what constitutes plan documents and their governing role

Documents included as plan documentsCertificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents

Governing role when conflicts ariseIf a conflict exists between this policy and any plan document under which a member is entitled to Covered Services, the plan document will govern

Provider contract precedenceIf a conflict exists between this policy and a provider contract, the provider contract will govern

First- and second-degree relatives definitions

First-degree relativesParents, full siblings, and children of the individual

Second-degree relativesGrandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings of the individual

Usage contextDefinitions apply to family-history–based reimbursement criteria for thrombosis risk testing

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OpenPayer

Venous and Arterial Thrombosis Risk Testing (laboratory reimbursement)

Reimbursement Criteria for Thrombosis Risk Testing

Procedure Codes and Timing Guidance

Documentation, Billing, and Denial-Risk Rules

Key Definitions