ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB047

Pancreatic Enzyme Testing for Acute Pancreatitis

Reimbursement and coding guidance for laboratory measurement of pancreatic enzymes (lipase, amylase, trypsin/trypsinogen/TAP, urinary amylase, and selected biomarkers) related to diagnosis and management of acute and chronic pancreatitis for BCBSOK plans and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPancreatic Enzyme Testing for Acute Pancreatitis

Policy CodePolicy CPCPLAB047

Change TypeAdded reimbursement exclusion for urinary amylaseclarifications and reference updates

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionDo not bill for measurement of urinary amylase concentration for the initial diagnosis of acute pancreatitis.

SourceLink

POLICY UPDATE CHANGES

For individuals presenting with signs and symptoms of acute pancreatitis, measurement of urinary amylase concentration for the initial diagnosis of acute pancreatitis is not reimbursable.

Other changes made for clarity and references revised.

lipase preferredpreferred test

not reimbursablenot reimbursable (multiple)

not reimbursabletrypsin-related tests

not reimbursablespecified biomarkers

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not reimbursableurinary amylase (initial)

Coverage and Reimbursement Criteria

Pancreatic enzyme and biomarker reimbursement criteria

Reimbursement rules for pancreatic enzyme and related biomarker testing

ALL of the following

ONE of
- For individuals presenting with signs and symptoms of acute pancreatitis, measurement of either serum lipase (preferred) or serum amylase may be reimbursable.

ALL of the following

ANY of
- As part of an ongoing assessment of therapy for acute pancreatitis.
- To determine the prognosis of pancreatitis.
- To determine the severity or progression of pancreatitis.
- More than once per visit.
- For the diagnosis, prognosis, or severity of chronic pancreatitis.
- As part of ongoing assessment or therapy of chronic pancreatitis.
- In asymptomatic nonpregnant individuals during general exam without abnormal findings.

ALL of the following

ANY of
- Measurement of serum and urine trypsin, trypsinogen, or trypsinogen activation peptide (TAP).
- Measurement of C-Reactive Protein (CRP).
- Measurement of Interleukin-6 (IL-6).
- Measurement of Interleukin-8 (IL-8).
- Measurement of Procalcitonin.

Measurement of urinary amylase concentration for the initial diagnosis of acute pancreatitis is NOT reimbursable.

Reimbursement exclusion

Reimbursement rule added in 7/17/2023 update:

Added exclusion: For individuals presenting with signs and symptoms of acute pancreatitis, measurement of urinary amylase concentration for the initial diagnosis of acute pancreatitis is not reimbursable.

Procedure Codes and Coding Guidance

Procedure codes (not exhaustive)mixed

No codes listed

Provider Responsibilities and Billing Rules

Documentation Required

Documentation and claim submission expectations

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code sets. Claims are subject to code edit protocols and claim review; upon request, providers are urged to submit any additional documentation.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG, etc.).
Follow industry-standard coding guidelines and code edit protocols.
Provide additional documentation upon request for claim review and adjudication.

Prior Authorization

Policy interpretation and precedence

BCBSOK may use reasonable discretion in interpreting and applying this policy; if a conflict exists, the member's plan document or the provider contract will govern.

Definitions and Reference Info

Acute Pancreatitis Signs and Symptoms

PainPersistent, severe epigastric pain (may localize to right upper quadrant in some patients)

Gastrointestinal symptomsNausea and vomiting

Atypical presentationApproximately 5–10% of patients with severe acute pancreatitis may have painless disease with unexplained hypotension

Abdominal exam findingsTenderness to palpation of the epigastrium; abdominal distention; hypoactive bowel sounds

Systemic signsFever, rapid pulse, tachypnea, hypoxemia, and hypotension

References

Urinary amylase/creatinine ratio

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPancreatic Enzyme Testing for Acute Pancreatitis

Policy CodePolicy CPCPLAB047

Change TypeAdded reimbursement exclusion for urinary amylaseclarifications and reference updates

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionDo not bill for measurement of urinary amylase concentration for the initial diagnosis of acute pancreatitis.

SourceLink

On This Page

Plan documents (e.g., Certificates of Benefits, benefit booklets, Summary Plan Descriptions) govern over this CPCP when conflicts arise.

Provider contracts govern over this CPCP when conflicts arise between the policy and contractual terms.

BCBSOK has full and final discretionary authority to interpret and apply the policy as provided under applicable plan documents.

Billing Rule

Urinary amylase not reimbursable for initial diagnosis of acute pancreatitis

Measurement of urinary amylase concentration for the initial diagnosis of acute pancreatitis is not reimbursable for individuals presenting with signs and symptoms of acute pancreatitis.

This exclusion was added to Reimbursement Information on 7/17/2023.

Urinary amylase / urinary creatinine ratio (uAm/uCr) — BMC Pediatrics study describing a less-invasive parameter for hyperamylasemia management

Biomarkers for severe APStudies on diagnostic value of serum C-reactive protein, procalcitonin, and interleukin-6 in severe acute pancreatitis (Clinica Chimica Acta, 2020)

GuidelinesGuidelines for management of acute pancreatitis (Toouli et al., J Gastroenterol Hepatol, 2002)

Trypsinogen and TAPMulticenter study on urinary trypsinogen-2 and trypsinogen activation peptide usefulness in acute pancreatitis (World J Gastroenterol)