CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB024

Epithelial Cell Cytology in Breast Cancer Risk Assessment

This document governs BCBSOK reimbursement for cytologic analysis of epithelial cells used to assess breast cancer risk and management of high-risk patients; it applies to providers submitting claims to Blue Cross and Blue Shield of Oklahoma and to members covered under BCBSOK plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEpithelial Cell Cytology in Breast Cancer Risk Assessment

Policy CodePolicy CPCPLAB024

Change TypeClarifiedRevisedAdded

Effective Date01/15/2025

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review; Reimbursement Information unchanged.

Revised statement to indicate all cytological analysis for breast cancer diagnosis is not reimbursable and added codes 88172, 88173, 88177.

New policy created.

5procedure codes listed

01/15/2025Plan effective date

Not reimbursablecoverage stance

10/30/2024approval date

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Coverage Criteria

Non-reimbursable cytology

Covered when ALL of the following are met:

ALL of the following

Cytologic analysis of epithelial cells to assess breast cancer risk and manage patients at high risk of breast cancer is not reimbursable.
Codes associated with the non-reimbursable service include 88108, 88112, 88172, 88173, 88177.

Policy note: This reimbursement stance applies to claims submitted for the listed CPT procedure codes; providers should refer to plan documents for benefit-specific coverage determinations.

Provider Actions & Claims Submission

Documentation Required

Documentation and claims submission — Submit accurate documentation and valid HIPAA codes; claims may be reviewed

Providers must submit accurate documentation of services performed and submit claims using valid HIPAA-approved code sets; claims are subject to code edit protocols and may be reviewed. Upon request, providers should submit any additional documentation.

Submit claims using valid code combinations from HIPAA-approved code sets (eg, CPT, HCPCS, ICD-10-CM/PCS, NDC).
Code claims appropriately per industry standard coding guidelines (eg, UB editor, AMA CPT guidance, CMS NCCI edits).
Claims are subject to code edit protocols and claim review against benefit coverage, provider contract language, medical policies, and coding software logic.
If requested, provide additional documentation to support the claim.

Definitions / Plan Documents

Plan documents — scope and provider responsibilities (Definitions)

DefinitionPlan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents that govern coverage when in conflict with this policy.

Governing authorityIf a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Provider contracts precedenceIf a conflict arises between this policy and any provider contract, the provider contract will govern.

Provider responsibilityProviders are responsible for submission of accurate documentation of services performed and for submitting claims using valid HIPAA-approved code sets.

Discretion and interpretationBlue Cross and Blue Shield of Oklahoma may use reasonable discretion interpreting and applying this policy and has final discretionary authority to the extent provided under applicable plan documents.