CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB058

Venous and Arterial Thrombosis Risk Testing

Reimbursement criteria and coding guidance for laboratory testing related to venous and arterial thrombosis risk (including protein C, protein S, antithrombin III, Factor V Leiden, and prothrombin G20210A), governing Blue Cross Blue Shield of Oklahoma claims and providers subject to plan documents.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyVenous and Arterial Thrombosis Risk Testing

Policy CodePolicy CPCPLAB058

Change TypeClarified and added reimbursement criteria

Effective DateAug 8, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation and claims using valid HIPAA code sets; additional documentation may be requested.

SourceLink

POLICY UPDATE CHANGES

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

Pulmonary embolism was added to the age-based reimbursement criterion (individuals <50 who experienced DVT/PE).

Plasma testing for protein C and protein S deficiency may be reimbursable for warfarin-induced skin necrosis or neonatal purpura fulminans.

Activated protein C (aPC) resistance assay is not reimbursable in all situations.

7listed procedure/assay codes

8enumerated reimbursement situations

6 wksminimum timing after event

1.0policy version

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyVenous and Arterial Thrombosis Risk Testing

Policy CodePolicy CPCPLAB058

Change TypeClarified and added reimbursement criteria

Effective DateAug 8, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation and claims using valid HIPAA code sets; additional documentation may be requested.

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.

Reimbursement Criteria and Exclusions

Reimbursement criteria and exclusions — plasma testing for protein C, protein S, antithrombin III

Plasma testing for protein C, protein S, and antithrombin III deficiency may be reimbursable in specified clinical situations when performed per timing guidance; some tests and situations are explicitly not reimbursable.

ANY of the following

ALL of the following
- Reimbursable: plasma testing for protein C, protein S, antithrombin III for individuals <50 who have experienced deep venous thrombosis (DVT) or pulmonary embolism (PE).
ALL of the following
- Reimbursable: plasma testing for individuals who have experienced DVT in unusual sites (e.g., hepatic, mesenteric, or cerebral veins).
ALL of the following
- Reimbursable: plasma testing for individuals who have experienced a DVT and who have a strong family history of thrombotic disease.
ALL of the following
- Reimbursable: plasma testing for individuals who are pregnant or taking oral contraceptives and who have experienced a DVT.
ALL of the following
- Reimbursable: first- and second-degree relatives of individuals who experienced a DVT before age 50. (See Note: first- and second-degree relative definitions.)
ALL of the following
- Reimbursable: women under age 50 who smoke and who have suffered a myocardial infarction.
ALL of the following
- Reimbursable: targeted testing before administration of oral contraceptives for individuals with a personal or family history of DVT.
ALL of the following
- Reimbursable: plasma testing for pediatric individuals who have suffered a pediatric arterial ischemic stroke.
ALL of the following
- Reimbursable: plasma testing for protein C and protein S deficiency for individuals with warfarin-induced skin necrosis or infants who develop neonatal purpura fulminans.
ALL of the following
- Assays for clotting inhibitors (amount and function) should be performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants; perform plasma assays prior to any molecular testing.

ANY of the following

ALL of the following
- Not reimbursable: venous thrombosis risk testing for superficial venous thrombosis (including superficial thrombophlebitis and varicosities).
ALL of the following
- Not reimbursable: all activated protein C/aPC resistance assay in all situations.
ALL of the following
- Not reimbursable: DVT risk testing as part of a pre-transplant evaluation.

Procedure Codes and Testing Timing

Listed laboratory procedure codes (not all-encompassing)CPT

85300
85301
85302
85303
85305
85306
85307

Timing for plasma assays after acute event

Minimum waiting periodPerform plasma testing at least six weeks after the acute thrombotic event.

Anticoagulant statusTesting should be performed while the patient is not taking anticoagulants.

Sequence with molecular testingAssays for clotting inhibitor amount and function should be performed prior to any molecular testing.

Documentation and Claims Submission

Documentation Required

Documentation and claims submission requirements

Providers must submit accurate documentation of services performed and submit claims using valid HIPAA-approved code sets; claims will be reviewed against plan documents, provider contracts, clinical payment and coding policies, and code edit protocols. Upon request, providers should supply any additional documentation to support the claim.

Submit claims using valid code combinations from HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.).
Code claims according to industry standard coding guidelines (e.g., Uniform Billing, AMA CPT, CMS NCCI edits).
Claims are subject to code edit protocols and review against benefit coverage, provider contracts, medical and clinical payment policies.
Provide additional documentation promptly if requested during claim review.

Relative Degree Definitions

First‑degree relatives

DefinitionFirst-degree relatives include parents, full siblings, and children of the individual.

Use in coverage criteriaApplied when determining eligibility for testing of relatives of individuals with early-onset DVT/PE (see reimbursement criteria).

ScopeRefers to biological relationships relevant to hereditary thrombophilia risk assessment.

Second‑degree relatives

DefinitionSecond-degree relatives include grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings of the individual.

Use in coverage criteriaApplied when determining eligibility for testing of relatives of individuals with early-onset DVT/PE (see reimbursement criteria).