CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO24

Epithelial Cell Cytology in Breast Cancer Risk Assessment

Reimbursement policy governing laboratory cytologic analysis of epithelial cells (e.g., nipple aspirate fluid, ductal lavage) to assess breast cancer risk for Blue Cross Blue Shield of Oklahoma members. Applies to providers submitting claims to BCBSOK; plan documents and provider contracts govern in conflicts.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEpithelial Cell Cytology in Breast Cancer Risk Assessment

Policy CodePolicy CPCPLABO24

Change TypeRevised — reimbursement and codes added

Effective DateMarch 1, 2024

Next Review Date

Key ActionDo not bill cytologic analysis of epithelial cells for breast cancer risk assessment as a reimbursable service and submit claims with accurate documentation using valid HIPAA-approved code sets.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information revised to indicate all cytological analysis for breast cancer diagnosis is not reimbursable.

Added procedure codes 88172, 88173, 88177 to the listed codes.

Not reimbursableCytologic analysis for breast cancer risk

5Procedure codes listed (example list)

2024-03-01Policy effective date

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Coverage Stance

This policy (CPCPLABO24) is not reimbursable for epithelial cell cytology when used to assess breast cancer risk or to manage patients at high risk of breast cancer. It governs reimbursement for laboratory cytologic analysis of epithelial cells (for example, nipple aspirate fluid and ductal lavage) submitted to Blue Cross Blue Shield of Oklahoma. Effective March 1, 2024.

Procedure Codes and Billing

Procedure codes listed as not reimbursable (example list)CPTNot Covered

88108	Cytopathology, cervical or vaginal (Pap test) — listed here as an example code included by policy (provider should verify applicability)
88112	Cytopathology, cervical or vaginal; requiring interpretation by physician (example inclusion)
88172	Cytopathology, other source, limited (added to policy)
88173	Cytopathology, other source, intermediate (added to policy)
88177	Cytopathology, other source, comprehensive (added to policy)

The procedure codes listed in this policy are presented as examples of services considered not reimbursable; inclusion of a code in the policy does not guarantee coverage or payment. Providers are responsible for submitting accurate documentation and claims using valid HIPAA-approved code sets and should verify applicability and coverage by reviewing product-specific plan documents before billing.

What Providers Must Do

Documentation Required

Accurate documentation and coding

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code sets and industry standard coding guidelines. Claims are subject to claim review and providers are urged to submit additional documentation when requested.

Submit additional documentation when requested

Billing Rule

Not reimbursable services — do not bill as covered

Cytologic analysis of epithelial cells to assess breast cancer risk and manage high-risk patients is not reimbursable; inclusion of a code in the policy does not guarantee coverage or reimbursement. Providers should review plan documents for product-specific applicability.

88108
88112
88172
88173
88177

Clinical and Administrative Background

BCBSOK based this reimbursement stance on a literature review and clinical guidance. The policy notes multiple references and guidelines were considered, including publications and guidance from the ACR, ASBS, NCCN, FDA, UpToDate, and several primary studies, and concludes that cytologic analysis of epithelial cells for breast cancer risk assessment is not reimbursable. This context supports the administrative application of the policy to providers submitting claims to BCBSOK and reiterates that plan documents govern in the event of conflict.

Policy Update Changes

03/01/2024RevisionLatest

Document updated with literature review; Reimbursement Information revised to indicate all cytological analysis for breast cancer diagnosis is not reimbursable and procedure codes 88172, 88173, and 88177 were added; references revised.

11/01/2023Revision

Document updated with literature review; reimbursement information unchanged; references revised.

11/01/2022Creation

New policy established (Policy Number: CPCPLABO24) with plan effective date March 1, 2024.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEpithelial Cell Cytology in Breast Cancer Risk Assessment

Policy CodePolicy CPCPLABO24

Change TypeRevised — reimbursement and codes added

Effective DateMarch 1, 2024

Next Review Date

SourceLink

On This Page

OpenPayer

Epithelial Cell Cytology in Breast Cancer Risk Assessment

Coverage Stance

Procedure Codes and Billing

What Providers Must Do

Clinical and Administrative Background

Defined Terms

Policy Update Changes

Epithelial Cell Cytology in Breast Cancer Risk Assessment

Coverage Stance

Procedure Codes and Billing

What Providers Must Do

Clinical and Administrative Background

Defined Terms

Policy Update Changes

Related Policies & References