CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO46

Cardiac Biomarkers for Myocardial Infarction

Defines BCBSOK reimbursement criteria for laboratory cardiac biomarker tests used in the diagnosis and prognosis of myocardial infarction for members; applies to providers submitting claims to Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCardiac Biomarkers for Myocardial Infarction

Policy CodePolicy CPCPLABO46

Change TypeNo material changes

Effective DateNov 1, 2022

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims may be reviewed and could require additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4max troponin tests (24-72h)

1.0policy version

Nov. 1, 2022plan effective date

multipleexcluded biomarkers

Reimbursement Criteria

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ALL of the following

ANY of the following troponin criteria
- Measurement of cardiac troponin (troponin T or I) for the diagnosis of myocardial infarction (MI) is reimbursable in patients presenting with signs and symptoms of acute coronary syndrome.
EXCLUSIONS (none of the following reimbursable for diagnosis/prognosis of MI)
- Measurement of the following cardiac biomarkers for the diagnosis and/or prognosis of MI is not reimbursable in patients presenting with signs and symptoms of acute coronary syndrome: Aspartate aminotransferase (AST/SGOT).
- Measurement of the following cardiac biomarkers for the diagnosis and/or prognosis of MI is not reimbursable in patients presenting with signs and symptoms of acute coronary syndrome: Cardiac creatine kinase isoenzyme MB (CK-MB).
- Measurement of the following cardiac biomarkers for the diagnosis and/or prognosis of MI is not reimbursable in patients presenting with signs and symptoms of acute coronary syndrome: Creatine kinase (CK) and creatine kinase isoenzymes.
- Measurement of the following cardiac biomarkers for the diagnosis and/or prognosis of MI is not reimbursable in patients presenting with signs and symptoms of acute coronary syndrome: Lactate dehydrogenase (LD/LDH).
- Measurement of the following cardiac biomarkers for the diagnosis and/or prognosis of MI is not reimbursable in patients presenting with signs and symptoms of acute coronary syndrome: Myoglobin.
- Measurement of the following cardiac biomarkers for the diagnosis and/or prognosis of MI is not reimbursable in patients presenting with signs and symptoms of acute coronary syndrome: Copeptin.
- Measurement of the following cardiac biomarkers for the diagnosis and/or prognosis of MI is not reimbursable in patients presenting with signs and symptoms of acute coronary syndrome: C-reactive protein (CRP).
- Measurement of the following cardiac biomarkers for the diagnosis and/or prognosis of MI is not reimbursable in patients presenting with signs and symptoms of acute coronary syndrome: Heart-type fatty acid binding protein (H-FABP).
- Measurement of other non-troponin cardiac biomarkers not listed above is not reimbursable for diagnosis and/or prognosis of MI.
Measurement of cardiac biomarkers in patients presenting with signs and symptoms of acute coronary syndrome in an outpatient setting that is not capable of performing reimbursable testing is not reimbursable.
Quantity limit: A maximum of 4 serial troponin tests will be reimbursed in the first 24-72 hours after presentation.<= 4 tests in first 24-72 hours

Coding and Limits

Coding standards and authoritative sourcesmixed

HIPAA-approved code sets	Health Insurance Portability and Accountability Act approved code sets (general requirement to use valid HIPAA-approved code sets)
UB	Uniform Billing (UB) editor guidance
AMA CPT	American Medical Association Current Procedural Terminology (CPT)
CPT Assistant	CPT Assistant guidance
HCPCS	Healthcare Common Procedure Coding System
ICD-10-CM/PCS	International Classification of Diseases, 10th Revision, Clinical Modification and Procedure Coding System
NDC	National Drug Codes
DRG	Diagnosis Related Group guidelines
CMS NCCI	Centers for Medicare & Medicaid Services National Correct Coding Initiative (NCCI) Policy Manual and CCI table edits

Maximum reimbursable serial troponin tests

Maximum reimbursable serial troponin tests4 tests reimbursed within the first 24-72 hours after presentation

Time window for limitFirst 24-72 hours after presentation

Applies toRepeat troponin measurements (serial troponin tests)

Claims Documentation & Billing Requirements

Documentation Required

Claims documentation and coding requirements

Providers are responsible for submitting accurate documentation of services performed and must bill using valid HIPAA‑approved code sets. Claims should be coded according to industry standard coding guidelines (for example, UB, AMA CPT, HCPCS, ICD‑10, NDC, DRG, CMS NCCI policy/manual and CCI table edits). Claims are subject to code edit protocols and review against benefit coverage, provider contracts, medical policies and coding software logic; upon request, providers must submit additional documentation.

Submit accurate clinical documentation supporting the services billed.
Use valid HIPAA‑approved code combinations (CPT, HCPCS, ICD‑10, NDC, DRG, etc.).
Expect claims to be reviewed and to provide additional documentation upon request.
Code claims per industry standard guidelines and CMS/NCCI edits.

Plan Documents and Clinical Definitions

Plan documents

Certificates of Health Care BenefitsIncluded as a plan document governing coverage determinations

Benefit bookletsIncluded as a plan document governing coverage determinations

Summary Plan Descriptions (SPDs)Included as a plan document governing coverage determinations

Other coverage documentsAny other plan documents that define member entitlement to Covered Services; plan documents govern if conflicts arise with this policy

Acute coronary syndrome/Myocardial infarction signs and symptoms

Chest pain and ischemic chest sensationsSqueezing, tightness, pressure, constriction, crushing, burning, fullness in chest; ischemic pain with radiation to arms, jaw, back; band-like sensation or heavy weight on chest

Shortness of breath and respiratory symptomsShortness of breath, dyspnea alone, belching

Autonomic and systemic symptomsDiaphoresis, nausea, vomiting, indigestion, dizziness, lightheadedness, clamminess, fatigue

Atypical and miscellaneous symptomsWeakness, epigastric pain or discomfort, palpitations, syncope, or cardiac arrest