ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB020

Cardiovascular Disease Risk Assessment

Defines BCBSOK reimbursement and coding guidance for laboratory tests used in cardiovascular disease (CVD) risk assessment for plan members and providers; applies to adults and references pediatric guidance for those under 18.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCardiovascular Disease Risk Assessment

Policy CodePolicy CPCPLAB020

Change TypeCoding additions and frequency clarifications

Effective DateMar 1, 2024

Next Review DateN/A

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; BCBSOK may request additional documentation and apply discretion when reviewing claims.

SourceLink

POLICY UPDATE CHANGES

Added codes 0415U and 0019M.

Allowed lipid panel screening on an annual basis for those with increased risk of dyslipidemia and added frequency to hs-CRP measurement.

Document updated with literature review; reimbursement information revised for clarity.

Every 4–6 yrsrecommended lipid screening interval for ages 18–79

Annuallylipid testing for increased-risk individuals

Not reimbursableLipoprotein(a) reimbursement

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Addedhs-CRP frequency clarified

Codes listedprocedure codes referenced

Coverage Criteria for CVD Risk Assessment Testing

COVERAGE CRITERIA FOR CVD RISK ASSESSMENT TESTING

Reimbursement Information: For individuals 18 years of age and older, lipid panel testing (see NOTE 1) and select biomarker testing may be reimbursable as specified below.

Lipid panel screening

Ages and routine screening
- To screen for cardiovascular disease (CVD) risk: every 4 to 6 years for individuals ages 18 to 79 years.
- Annually for individuals at increased risk for cardiovascular disease as determined by 2013 ACC/AHA Pooled Cohort Equations (PCEs) to calculate 10-year risk of CVD events (see NOTE 2).
Increased risk for dyslipidemia
- Annually for individuals with obesity or metabolic syndrome.
- Annually for individuals with nephrotic syndrome.
- Annually for individuals with hypothyroidism.
- Annually for individuals with hyperthyroidism.
- Annually for individuals with pancreatitis.
- Annually for individuals with diabetes.
- Annually for individuals with chronic kidney disease.
- Annually for individuals with Cushing Syndrome.
- Annually for individuals who are pregnant.
- Annually for individuals with cholestatic liver disease.
- Annually for individuals with lipid metabolism disorders (e.g., Gaucher disease in adults).
Monitoring with lipid-lowering or other therapies
- To establish baseline levels before initiating statin therapy.
- Every 4 to 12 weeks after initiation or change of statin therapy.
- Annually when no medication changes have occurred while on statin therapy.
- For individuals on long-term drug therapy that requires lipid monitoring (e.g., isotretinoin/Accutane, certain antipsychotics): frequency per clinical need and product labeling.
- For HIV-positive individuals about to begin or currently receiving antiretroviral therapy (ART): to establish baseline before initiating ART; every 1 to 3 months after initiation or change of therapy; every 6 to 12 months when no medication changes have occurred.

Apolipoprotein B (apoB)

Individuals with hypertriglyceridemia.
Individuals with diabetes mellitus.
Individuals with obesity or metabolic syndrome.
Individuals with other dyslipidemias (such as very low LDL-C).
Individuals who are on lipid therapy (for monitoring/management).
Individuals suspected to have familial dysbetalipoproteinemia or familial combined hyperlipidemia.

Policy Update History

Policy Update History: summary of recent changes relevant to coverage determinations and coding.

03/01/2024: Added codes 0415U and 0019M. No other changes made.

11/01/2023: Document updated with literature review. Reimbursement Information revised for clarity; added frequency to allow annual lipid panel screening for those with increased risk of dyslipidemia; added frequency for hs-CRP measurement.

11/01/2022: New policy.

Billing and Coding Guidance

Procedure codes referencedCPT

80061	Lipid panel / cholesterol tests (example code listed)
81599	Unlisted multianalyte assay with algorithmic analysis (example code listed)
82172	Cholesterol, direct measurement (example code listed)
82465	Apolipoprotein B test (example code listed)
82610	Cholesterol, HDL (example code listed)
83090	C-reactive protein; high-sensitivity (example code listed)
83695	Lipoprotein electrophoresis (example code listed)
83698	Lipoprotein particle analysis (example code listed)
83700	Lipoprotein, direct measurement (example code listed)
83701	Lipoprotein fractionation (example code listed)

1–10 of 30

1/3

Recently added codesCPT

0415U	Code added to policy (description not provided in this section)
0019M	Code added to policy (description not provided in this section)

inv-07: Lipid screening frequency (ages 18–79)

Recommended interval (ages 18–79)Every 4 to 6 years

Increased-risk individualsAnnually (per 2013 ACC/AHA Pooled Cohort Equations)

Baseline and monitoring with statin therapyBaseline before initiation; every 4–12 weeks after initiation/change; annually if stable

inv-08: No thresholds provided

Thresholds defined in this sectionNone — this section contains references only and does not specify numeric coverage thresholds

Content typeBibliographic citations to guidelines, systematic reviews, and research articles

Provider Responsibilities and Actions

Documentation Required

Documentation and Claim Submission Responsibility

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and industry-standard coding guidelines (e.g., UB, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI policy manual and edits). Claims are subject to code edit protocols and claim review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, BCBSOK may require additional documentation to substantiate services billed.

Submit claims using valid HIPAA-approved code sets and industry-standard coding guidelines.
Be prepared to provide additional documentation upon request to support billed services.

Note

References — Supporting Literature

References supporting clinical and coding guidance for this policy include peer-reviewed literature and diagnostic resource materials. Providers may refer to the listed sources for clinical context and justification when submitting documentation.

Definitions and Evidence Base

inv-14: Simple lipid panel

DefinitionSimple lipid panel generally includes total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides

Additional reportsCertain calculated ratios (e.g., total/HDL cholesterol) may also be reported

Excluded componentsApolipoproteins, particle number/size, and lipoprotein(a) are not components of a simple lipid panel

inv-15: Increased CVD risk

DefinitionIncreased CVD risk defined using 2013 ACC/AHA Pooled Cohort Equations (PCEs) to calculate 10-year risk

Examples of risk-enhancing conditionsObesity or metabolic syndrome, diabetes, chronic kidney disease, nephrotic syndrome, thyroid disease, pancreatitis, pregnancy, cholestatic liver disease, lipid metabolism disorders

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCardiovascular Disease Risk Assessment

Policy CodePolicy CPCPLAB020

Change TypeCoding additions and frequency clarifications

Effective DateMar 1, 2024

Next Review DateN/A

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; BCBSOK may request additional documentation and apply discretion when reviewing claims.

SourceLink

On This Page

Implication for coverageCoverage stance and numeric thresholds expected elsewhere in the policy document

inv-09: Lipid panel screening frequency (increased-risk individuals)

Frequency for increased-risk individualsAnnual lipid panel screening is allowed for individuals at increased risk of cardiovascular disease

Risk definition referenceIncreased risk defined using 2013 ACC/AHA PCEs to calculate 10-year risk

Additional increased-dyslipidemia conditionsAnnual screening also allowed for conditions such as obesity, diabetes, CKD, nephrotic syndrome, thyroid disease, pancreatitis, pregnancy, cholestatic liver disease, lipid metabolism disorders

inv-10: hs-CRP measurement frequency

hs-CRP frequency statusMeasurement frequency was added/clarified in the policy update (see Policy Update History) — exact interval is specified elsewhere in the policy

Use casehs-CRP reimbursable when risk-based treatment decision is uncertain after PCE assessment (per coverage criteria)

Follow-up allowanceIf initial hs-CRP is abnormal, follow-up allowed up to once per year (detailed intervals in full policy)

Garber AJ, et al. CONSENSUS STATEMENT… Comprehensive Type 2 Diabetes Management Algorithm — 2020 Executive Summary. Endocrine Practice. 2020.
Garg PK, et al. Lipoprotein-associated phospholipase A2 and risk of incident cardiovascular disease. Atherosclerosis. 2015.
Genova Diagnostics. Cardio Check. 2023 sample report.
Gibson M, Morrow D. Elevated cardiac troponin concentration in the absence of an acute coronary syndrome. 2022.

Billing Rule

Coding Updates

Coding updates to this policy were made to reflect new, billable codes. Providers should use the updated codes when submitting claims and ensure claim coding aligns with applicable coding guidance and payer edit logic.

03/01/2024: Added codes 0415U and 0019M — providers must use these codes where applicable.
Continue to follow industry coding guidelines and the BCBSOK claim edit protocols when billing.

Clinical applicationPCE estimate may be individualized with additional risk-enhancing factors during clinician-patient risk discussion

inv-16: References

Representative citationsGoff DC et al., 2013 ACC/AHA guideline on assessment of cardiovascular risk; Garber AJ et al., AACE/ACE consensus; European Society of Cardiology prevention guideline

Types of sourcesClinical practice guidelines, consensus statements, systematic reviews, and original research articles

PurposeReferences inform policy recommendations for CVD risk assessment and biomarker use

inv-17: Guideline and evidence base

Guideline sources citedEuropean Society of Cardiology (ESC) prevention guideline

Guideline sources citedAmerican College of Cardiology/American Heart Association (ACC/AHA) guidelines (eg, 2013 PCEs, 2017 hypertension guideline)

Other sourcesUSPSTF statements, National Lipid Association statements, American Society for Preventive Cardiology clinical practice statement