ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB035

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Defines reimbursement criteria for serologic and algorithm-based laboratory tests used in the workup and monitoring of IBD for members covered by Blue Cross and Blue Shield of Oklahoma; applies to providers submitting claims to BCBSOK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeCoding update; content clarifications and literature updates

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionUse the newly added code 0598U (effective 10/01/2025) where applicable when submitting reimbursement claims.

SourceLink

POLICY UPDATE CHANGES

Added code 0598U effective 10/01/2025.

Reimbursement information revised to include ibs-smart™ as example in #2.

Document updated with literature review and references revised/updated across multiple updates.

Policy created as a new policy on 11/1/2022.

11+non-reimbursable serologic markers

yesalgorithm-based tests not reimbursed

13procedure codes listed

Aug 1, 2025policy approval date

Coverage Criteria for IBD Laboratory Testing

Non-reimbursable serologic and algorithm-based tests

Reimbursement exclusions for specific serologic markers and algorithm-based tests in IBD workup/monitoring:

ALL of the following

These serologic markers are not reimbursable for the workup or monitoring of inflammatory bowel disease (IBD):
Non-reimbursable serologic markers (examples)
- Anti-neutrophil cytoplasmic antibody (ANCA)
- AntiSaccharomyces cerevisiae antibody (ASCA)
- Perinuclear anti-neutrophilic cytoplasmic antibody (pANCA)
- Antibody to Escherichia coli outer membrane porin C (anti-OmpC)
- Antibody to Pseudomonas fluorescens-associated sequence I2 (anti-I2)
- Anti-CBir1 flagellin antibody (anti-cBir1)
- Antichitobioside antibodies (ACCA IgA)
- Antilaminaribioside antibodies (ALCA IgG)
- Antimannobioside antibodies (AMCA IgG)
- Pyruvate kinase M2 (PKM2)
This list is not necessarily exhaustive; policy states these are not reimbursable for IBD workup and monitoring.

Non-reimbursable algorithm-based diagnostic panels

Diagnostic algorithm-based testing:

ALL of the following

Algorithm-based diagnostic panels are not reimbursable for the diagnosis or monitoring of individuals with IBD.
Examples of algorithm-based diagnostic panels not reimbursable
- ibs-smart™
- Prometheus® testing

Evidence base and reimbursement examples

Policy citations and literature informing coverage decisions include guideline and research references on serologic markers, fecal biomarkers, genetic studies, diagnostic panels, and examples referenced in reimbursement guidance.

ALL of the following

Policy references multiple peer-reviewed and guideline sources addressing the diagnostic performance and clinical utility of serologic markers, fecal biomarkers, genetic testing, and diagnostic panels in IBD (examples below).
Selected references cited in the policy
- Liu JZ et al., Nat Genet (2015) — association analyses identifying susceptibility loci for IBD
- Maaser C. et al., ECCO-ESGAR Guideline for Diagnostic Assessment in IBD (2019) — guidance on initial diagnosis and monitoring
- Menees SB et al., Am J Gastroenterol (2015) — meta-analysis on CRP, ESR, fecal calprotectin, and lactoferrin

Procedure Codes and Effective Dates

Listed procedure codesmixed

82397
83516
83520
86021
86036
86037
86255
86671
88346
88350

1–10 of 13

1/2

Recently added codesCPT | HCPCS

0598U

Newly added code referenced in policy update history

Code effective date

Code effective date10/01/2025

Policy effective date (header)October 1, 2025

Policy approval/last review dateAugust 1, 2025

Provider Documentation and Billing Actions

Documentation Required

Provider documentation and claims review — guidance that providers must submit accurate documentation and may be asked for additional records

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims using valid code combinations from HIPAA-approved code sets and to follow industry-standard coding guidelines (e.g., UB Editor, AMA CPT, HCPCS, ICD-10-CM/PCS, 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. Upon request, providers must submit additional documentation to support the claim.

Submit accurate and complete clinical documentation upon request.
Code claims according to industry-standard guidelines and approved code sets.
Claims may be reviewed and edited based on plan benefits, contracts, policy rules, and coding software.

Definitions and Examples

Plan documents / BCBSOK discretion

Definition of plan documentsIncludes Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents

Hierarchy in conflictsIf a conflict exists between this policy and a plan document, the plan document governs; if conflict with a provider contract, the provider contract governs

BCBSOK discretionBlue Cross and Blue Shield of Oklahoma may use reasonable discretion in interpreting and applying this policy; BCBSOK has final discretionary authority as provided under applicable plan documents

Prometheus tests

Prometheus IBD sgiReferenced among diagnostic panels and serologic/biomarker panels considered in the policy literature and reimbursement discussion

Prometheus (example usage)

Policy Revision History

08/01/2025policy updateLatest

Policy updated and set with an effective date of 10/01/2025; added CPT/HCPCS code 0598U effective 10/01/2025.

10/30/2024literature update

Document updated with literature review; reimbursement information revised to include ibs-smart™ as an example and references were revised/updated.

02/01/2024literature update

Document updated with literature review; reimbursement information unchanged and references revised.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeCoding update; content clarifications and literature updates

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionUse the newly added code 0598U (effective 10/01/2025) where applicable when submitting reimbursement claims.

SourceLink

On This Page

Plevy S. et al., Inflamm Bowel Dis (2013) — combined serological, genetic, and inflammatory marker study differentiating IBD subtypes

Prometheus product information and critiques (Prometheus IBD sgi; commentary noting predictive value may be due to a subset of components)

Multiple systematic reviews, AGA and ECCO guideline publications, and UpToDate summaries referenced in the policy for context and evidence synthesis

Operational/reimbursement examples included in the policy update history: ibs-smart™ is listed as an example in the diagnostic algorithm exclusion, and code 0598U was added to the coding list effective 10/01/2025.

Coding update — 0598U addition and provider action to use updated coding effective 10/01/2025

Effective 10/01/2025, add CPT® code 0598U. Providers should begin using the updated coding on or after the effective date when billing for the described service. Ensure claims include correct code and supporting documentation per policy requirements.

Code added: 0598U — effective 10/01/2025.
Action: Use CPT code 0598U for applicable services billed on or after 10/01/2025 and include required documentation.

Prometheus testing is listed as an example of algorithm-based diagnostic panels in the policy's non-reimbursable testing discussion

Evidence contextPrometheus panels are included in the policy's referenced literature and reimbursement examples informing coverage decisions

ibs-smart™

ibs-smart™ (example)Listed in the reimbursement information as an example of an algorithm-based diagnostic panel referenced in the policy update

Reimbursement mentionibs-smart™ was added to examples in Reimbursement Information during the 10/30/2024 update noted in policy history

Context of listingAppears among examples of algorithm-based tests that the policy addresses for IBD diagnosis/monitoring

11/01/2023literature update

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

11/01/2022policy addition

Policy created as a new policy (initial establishment of policy).