ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB046

Biomarkers for Myocardial Infarction and Chronic Heart Failure

Reimbursement and coding policy describing when specific cardiac biomarker laboratory tests (troponin, BNP/NT-proBNP, and others) are reimbursable or not in outpatient settings for diagnosis/prognosis of myocardial infarction and heart failure; applies to providers billing BCBSOK plans and subject to individual plan documents.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyBiomarkers for Myocardial Infarction and Chronic Heart Failure

Policy CodePolicy CPCPLAB046

Change TypeMaterial additions and clarifications (BNP/NT-proBNP reimbursable criteriaadded non-reimbursable itemscode addition)

Effective Date03/01/2024

Next Review Date

Key ActionProviders must submit accurate documentation and review plan documents for product-specific reimbursement applicability.

SourceLink

POLICY UPDATE CHANGES

Measurement of B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) may be reimbursable in specified situations including diagnosis of heart failure in individuals presenting with dyspnea and to establish disease severity in chronic heart failure (up to four times per year outpatient).

Edited reimbursement guidance for clarity, changing wording from 'for all situations' to 'in the outpatient setting' for a specified item.

Added CPT/analysis code 88380 to the policy.

For all situations, qualitative measurement of cardiac troponin (troponin T or I) is not reimbursable.

For all situations in the outpatient setting, analysis of ST2 and/or its isoforms (e.g., Presage ST2) is not reimbursable.

up to 4troponin tests within 72 hrs (outpatient capable of MI eval)

up to 4/yr

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Coverage Criteria for Cardiac Biomarkers

Reimbursement criteria — policy updates and clarifications

Summary of reimbursement positions added or clarified in the policy update history:

Added reimbursement allowance: Measurement of B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) may be reimbursable in the outpatient setting for: a) diagnosis of heart failure in individuals presenting with dyspnea; and b) establishing disease severity in chronic heart failure (up to four times per year).

Clarification: Edited language to specify scope as 'in the outpatient setting' (applied to prior guidance on qualitative troponin and ST2 testing).

Added non-reimbursable positions (prior updates): Qualitative measurement of cardiac troponin (troponin T or I) is not reimbursable for all situations; analysis of ST2 and/or its isoforms (e.g., Presage ST2) is not reimbursable in the outpatient setting for all situations.

Coding update: CPT/analysis code 88380 was added to the policy coding list.

Procedure and Billing Codes

Listed laboratory procedure codesmixed

82550
82552
82553
82554
82725
83006
83615
83625
83874
83880

1–10 of 16

1/2

Added codeCPT

88380

Added to policy coding list (document did not supply full descriptor)

inv-05: troponin frequency threshold

ThresholdQuantitative cardiac troponin (T or I) may be reimbursable up to four times within the first 72 hours following initial presentation for individuals presenting with signs/symptoms of acute coronary syndrome when tested at an outpatient facility capable of performing an adequate clinical MI evaluation.

Setting limitationApplies only when testing is performed at an outpatient facility capable of performing an adequate clinical MI evaluation; measurements at sites not capable (e.g., independent lab or physician's office) are not reimbursable.

Test typeApplies to quantitative measurement of cardiac troponin (troponin T or I).

inv-06: BNP/NT-proBNP frequency threshold

ThresholdMeasurement of BNP or NT-proBNP may be reimbursable to establish disease severity in individuals with chronic heart failure up to four times per year in the outpatient setting.

Provider Documentation and Reimbursement Notes

Documentation Required

Provider documentation and plan-specific applicability — providers must submit accurate documentation and may be asked to provide additional documentation upon request; reimbursement requirement and plan applicability notes.

Providers are responsible for submission of accurate documentation of services performed and may be asked to submit additional documentation upon request. Claims must be coded using HIPAA-approved code sets and in accordance with industry standard coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI). Claims are subject to code edit protocols and review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Providers should review plan documents for product-specific applicability and eligibility for reimbursement.

Providers must submit accurate documentation and may be asked to provide additional documentation upon request.
Claims must be coded using valid HIPAA-approved code sets and industry coding guidelines.
Providers should review plan documents for product-specific applicability; not all requirements apply to every product.

Definitions and Clinical Context

inv-09: Acute Coronary Syndrome (ACS) signs/symptoms

Chest pain featuresIschemic chest pain with radiation to an upper extremity, both arms, diaphoresis, or with nausea and vomiting.

Descriptors of painSqueezing, tightness, pressure, constriction, crushing, burning, heartburn, fullness, band-like sensation, knot in center of chest, or pain radiating to jaw/teeth/back/epigastrium.

Associated symptomsShortness of breath, belching, nausea, indigestion, vomiting, diaphoresis, dizziness, lightheadedness, clamminess, and fatigue.

inv-10: Atypical ACS presentation

Atypical presentationsDyspnea alone; weakness; nausea and/or vomiting; epigastric pain or discomfort.

Other atypical signsPalpitations, syncope, or cardiac arrest.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyBiomarkers for Myocardial Infarction and Chronic Heart Failure

Policy CodePolicy CPCPLAB046

Change TypeMaterial additions and clarifications (BNP/NT-proBNP reimbursable criteriaadded non-reimbursable itemscode addition)

Effective Date03/01/2024

Next Review Date

Key ActionProviders must submit accurate documentation and review plan documents for product-specific reimbursement applicability.

SourceLink

On This Page

Billing Rule

Reimbursement Information updates — policy adds CPT code 88380; reimbursement guidance updated regarding BNP/NT-proBNP, qualitative troponin not reimbursable, and ST2 not reimbursable in outpatient setting; includes dates of changes.

Reimbursement Information updates: policy revisions effective 03/01/2024 added CPT code 88380 and clarified BNP/NT-proBNP reimbursement; previous updates on 11/01/2023 clarified non-reimbursement of qualitative troponin and ST2 in outpatient settings. Providers should bill accordingly and verify outpatient frequency limits and non-covered tests before submitting claims.

03/01/2024: Added CPT code 88380.
03/01/2024: Measurement of BNP or NT-proBNP may be reimbursable in any of the following situations: a) to diagnose heart failure in individuals presenting with dyspnea; b) to establish disease severity in individuals with chronic heart failure (up to four times per year in the outpatient setting).
11/01/2023: Qualitative measurement of cardiac troponin (troponin T or I) is not reimbursable.
11/01/2023: For all situations in the outpatient setting, analysis of ST2 and/or its isoforms (e.g., Presage ST2) is not reimbursable.
Providers should confirm plan-specific coverage and reimbursement rules prior to billing.

inv-11: References / Guidelines

European Society of Cardiology (ESC) Guidelines2016 and 2021 ESC guidelines for diagnosis and management of acute and chronic heart failure and chronic coronary syndromes cited.

ACC/AHA and NICE guidance2017 ACC/AHA focused update and NICE guidance on chest pain and high-sensitivity troponin tests referenced for clinical context.

Biomarker and trial literatureStudies and reviews on troponin assay performance, copeptin, ST2, H-FABP, and natriuretic peptides (e.g., CHOPIN trial, Framingham Heart Study) cited to support biomarker context.

Clinical reviews and consensusUpToDate review and International ST2 Consensus Panel publications cited for biomarker interpretation and prognostic use.