CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB026

Fecal Calprotectin Testing in Adults

Reimbursement and coding policy governing fecal calprotectin laboratory testing for Blue Cross and Blue Shield of New Mexico members; applies to providers submitting claims and to adults (18+).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyFecal Calprotectin Testing in Adults

Policy CodePolicy CPCPLAB026

Change TypeAge restriction and clarifications

Effective DateJan 15, 2025

Next Review Date

Key ActionSubmit claims using valid HIPAA-approved code sets and be prepared to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Added a note indicating this policy is specific to individuals 18 years of age or older and that criteria do not apply to individuals less than 18 years of age.

Reimbursement Information statements revised for clarity regarding adult testing relevance and use cases (differential diagnosis and monitoring/relapse/response to therapy).

References updated and literature review incorporated.

1Procedure code listed

18+Applies to age

3Reimbursement positions

CPCPLAB026Policy ID

Reimbursement Criteria

Reimbursement criteria (adults 18+)

Policy applies to individuals 18 years and older. Reimbursement positions are:

Note: This policy is specific to individuals 18 years of age or older. Criteria below do not apply to individuals less than 18 years of age.

Reimbursable (with criteria)

Fecal calprotectin testing for the differential diagnosis between noninflammatory gastrointestinal disease (e.g., IBS) and inflammatory gastrointestinal disease (e.g., IBD) may be reimbursable.
Fecal calprotectin testing to assess response to therapy, for relapse, or to monitor gastrointestinal conditions such as inflammatory bowel disease (IBD) may be reimbursable.

Not reimbursable: Fecal calprotectin testing for all other situations not discussed above is not reimbursable.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyFecal Calprotectin Testing in Adults

Policy CodePolicy CPCPLAB026

Change TypeAge restriction and clarifications

Effective DateJan 15, 2025

Next Review Date

Key ActionSubmit claims using valid HIPAA-approved code sets and be prepared to provide additional documentation upon request.

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.

Claims Submission and Review

Documentation Required

Claims submission, code edits, and documentation requests

Providers must submit claims using valid HIPAA‑approved code sets and accurate industry-standard coding guidelines. Claims are subject to code edit protocols and claim review, and BCBSNM may request additional documentation to support the claim.

Submit claims using valid code combinations from HIPAA-approved code sets (CPT, HCPCS, ICD-10, etc.).
Claims will be reviewed against code edit protocols, plan documents, provider contracts, medical and coding policies, and coding software logic.
Provide additional documentation upon request to support medical necessity and coding.

Scope and Definitions

inv-03: Description of policy scope — Lab management reimbursement criteria

ScopeBCBSNM lab management reimbursement criteria governing fecal calprotectin testing for members; not all requirements apply to every product—review plan documents for eligible coverage.

Applicable testingFecal calprotectin testing for differential diagnosis between noninflammatory GI disease (e.g., IBS) and inflammatory GI disease (e.g., IBD) may be reimbursable.

Monitoring/responseFecal calprotectin testing to assess response to therapy, for relapse, or to monitor gastrointestinal conditions such as IBD may be reimbursable.

Non‑reimbursable usesFecal calprotectin testing for all other situations not discussed above is not reimbursable.

Provider guidanceProviders are urged to review individual Plan documents for specific coverage and eligibility requirements.

inv-05: Adult — Adults 18 years of age or older — policy criteria apply only to this age group; does not apply to individuals under 18.

Age applicabilityPolicy is specific to individuals 18 years of age or older; criteria do not apply to individuals less than 18 years of age.

Adult definitionAdults = 18 years of age and older for the purposes of this policy.

Inapplicability to minorsAny claims or testing for individuals under 18 should not be evaluated under these criteria—refer to applicable pediatric coverage policies or plan documents.

OpenPayer

Fecal Calprotectin Testing in Adults

Reimbursement Criteria

Procedure Codes and Coding Guidance

Claims Submission and Review

Scope and Definitions