ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB020

Cardiovascular Disease Risk Assessment (laboratory testing) reimbursement

BCBSOK Clinical Payment and Coding Policy governing reimbursement for laboratory testing used in cardiovascular disease (CVD) risk assessment for members and providers; plan documents and provider contracts govern in conflicts.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCardiovascular Disease Risk Assessment (laboratory testing) reimbursement

Policy CodePolicy CPCPLAB020

Change TypeCodes addedfrequency and reimbursement clarifications

Effective DateMarch 1, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation; claims are subject to claim review and must use valid HIPAA-approved code sets.

SourceLink

POLICY UPDATE CHANGES

Added codes 0415U and 0019M.

Allowed lipid panel screening on an annual basis for those with increased risk of dyslipidemia (frequency added to 1b).

Added frequency to #4 for hs-CRP measurement.

Document updated with literature review.

annualallowed lipid screening frequency for increased-risk patients

4-6 yrsrecommended lipid screening interval (ages 18-79)

2new CPT/HCPCS-type codes added

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most recent policy update date

Not reimbursableLipoprotein(a) reimbursement status

Not reimbursablehs-cTnT reimbursement status

Coverage and Medical Necessity

CVD laboratory reimbursement criteria — reimbursable and non-reimbursable testing rules for adults (≥18 years) and other CVD biomarkers

Reimbursement Information: For individuals 18 years of age and older, lipid panel testing (see NOTE 1) and other cardiovascular (CVD) biomarker testing may be reimbursable or non‑reimbursable as described below.

ALL of the following

Lipid panel testing (simple lipid panel as defined in NOTE 1) may be reimbursable for individuals ≥18 years of age under any of the following conditions:
A. Screening 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 defined by 2013 ACC/AHA Pooled Cohort Equations [PCEs] to calculate 10‑year risk of CVD events; see NOTE 2).
B. Increased risk of dyslipidemia (annual allowed)
- Obesity or metabolic syndrome.
- Nephrotic syndrome.
- Hypothyroidism.
- Hyperthyroidism.
- Pancreatitis.
- Diabetes.
- Chronic kidney disease.
C. Statin therapy monitoring
- To establish baseline levels before initiating statin therapy.
- Every 4 to 12 weeks after initiation or change of therapy.
- Annually when no medication changes have occurred.
For individuals on long‑term drug therapy that requires lipid monitoring (e.g., isotretinoin, certain antipsychotics).
For HIV‑positive individuals starting or receiving antiretroviral therapy (ART): baseline before initiating ART; every 1 to 3 months after initiation/change; every 6 to 12 months when no medication changes have occurred.

References-only — no criteria

References-only — no coverage criteria present in this excerpt. The following references are provided to support the policy content and clinical context.

ALL of the following

See References section for cited literature and supporting documents, including guideline sources and studies relevant to lipid testing and CVD biomarkers.
NOTE 1: A simple lipid panel includes total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. Calculated ratios (e.g., total/HDL) may be reported. Apolipoproteins, particle number/size, Lp(a), and similar tests are not components of a simple lipid panel.
NOTE 2: 2013 ACC/AHA Pooled Cohort Equations (PCEs) are referenced for 10‑year CVD risk estimation; clinicians may individualize risk assessment using PCE plus additional risk‑enhancing factors as appropriate.

Coverage criteria and billing updates — summary of coverage-related changes and frequency allowances from policy update history

Coverage criteria and billing updates — summary of coverage-related changes, additions of codes, and frequency allowances from the policy update history.

ALL of the following

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; frequency added to allow annual lipid panel screening for those with increased risk of dyslipidemia; frequency added to hs‑CRP measurement (#4). References revised.
11/01/2022: Policy created (New policy).

Procedure Codes, Frequency, and Coding Notes

Example procedure codesCPT | HCPCS | mixed

80061	Lipid panel (example listed)
82465	Apolipoprotein B (listed)
83700	Lipoprotein, direct measurement (listed)
84478	C-reactive protein, cardiac (hsCRP) (listed)

No billing or CPT/HCPCS/ICD codes present in this excerptmixed

No codes listed

newly added codesCPT | HCPCS

0415U
0019M

Lipid screening interval (ages 18-79)

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

Annual allowance for increased-risk individualsAnnually for individuals at increased risk for cardiovascular disease (per 2013 ACC/AHA PCEs)

Statin therapy monitoringBaseline before initiating statin therapy; every 4–12 weeks after initiation/change; annually if no medication changes

Lipid panel screening frequency for increased-risk

Annual frequency allowanceLipid panel screening may be performed annually for individuals at increased risk for cardiovascular disease or increased risk of dyslipidemia

Documentation, Billing, and Provider Notices

Documentation Required

Documentation and claim review — providers must submit accurate documentation

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and appropriate coding per industry standards (UB, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI/CCI edits). Claims are subject to claim review for benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should supply additional documentation to support services billed.

Submit claims with valid HIPAA-approved codes and appropriate coding per industry standards (CPT, HCPCS, ICD-10, NDC, UB, DRG, CMS/NCCI/CCI).
Claims are subject to claim review and may require submission of additional documentation upon request.

Note

References (portion)

References (selected portion). These references informed policy content but do not impose additional prior authorization or step therapy requirements.

Definitions and Guideline References

Simple lipid panel — definition

TermSimple lipid panel

Typical componentsTotal cholesterol; LDL cholesterol; HDL cholesterol; Triglycerides

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

Not includedApolipoproteins, lipid particle number/size, and lipoprotein(a) are not considered components of a simple lipid panel

Clinical practice guidelines

Guidelines cited2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (PCEs)

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCardiovascular Disease Risk Assessment (laboratory testing) reimbursement

Policy CodePolicy CPCPLAB020

Change TypeCodes addedfrequency and reimbursement clarifications

Effective DateMarch 1, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation; claims are subject to claim review and must use valid HIPAA-approved code sets.

SourceLink

On This Page

Cholestatic liver disease.

Lipid metabolism disorders (e.g., Gaucher disease in adults).

Definition of increased risk (reference)

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

Conditions warranting annual testingObesity/metabolic syndrome, nephrotic syndrome, thyroid disease, pancreatitis, diabetes, chronic kidney disease, pregnancy, cholestatic liver disease, lipid metabolism disorders

hs-CRP measurement frequency

hs-CRP frequency clarificationFrequency for hs-CRP measurement was specified in the 11/01/2023 revision; follow-up testing allowed up to once per year when initial results are abnormal

Initial testing guidanceInitial screening may include two measurements ≥2 weeks apart when risk-based treatment decision is uncertain

Other CRP testingAll other CRP testing for CVD risk (outside specified hs-CRP guidance) is not reimbursable

Billing Rule

Reimbursement updates and code additions

Reimbursement updates and code additions effective 03/01/2024: codes 0415U and 0019M were added. Prior reimbursement clarification (11/01/2023) included: addition of frequency to allow lipid panel screening annually for those with increased risk of dyslipidemia; addition of frequency for hs-CRP measurement. No other changes were made on 03/01/2024.

Added CPT/other codes: 0415U, 0019M (effective 03/01/2024).
Frequency updates: lipid panel screening allowed annually for individuals at increased risk of dyslipidemia; frequency guidance added for hs-CRP measurement (see Reimbursement Information).

2018/2019 AHA/ACC and related cholesterol and prevention guidelines (AHA/ACC/ESC referenced in policy)

Guidelines cited2017 ACC/AHA guideline for high blood pressure prevention/detection (Whelton et al.)

Guideline useProviders should refer to referenced clinical guidelines and perform clinician–patient risk discussions to individualize risk

References

Selected references (examples)USPSTF. Risk assessment for cardiovascular disease with nontraditional risk factors: JAMA 2018;320:272-280; Visseren et al., 2021 ESC Guideline; Whelton PK et al., 2018 (2017 ACC/AHA BP guideline)

National statementsCDC/AHA statement on markers of inflammation and cardiovascular disease (Pearson et al., 2003)

Lipid guidelines and statements2021 Canadian Cardiovascular Society Guideline for Management of Dyslipidemia; National Lipid Association statements on lipid measurements

Policy update historyPolicy updated 11/01/2023 (literature review and frequency clarifications) and 03/01/2024 (added codes 0415U and 0019M)