CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO16

Pediatric Preventive Screening

Defines lab management reimbursement criteria for preventive screening tests in individuals from newborn through age 18 (with some exceptions) for Blue Cross Blue Shield of Oklahoma; affects providers submitting claims for pediatric preventive lab services.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPediatric Preventive Screening

Policy CodePolicy CPCPLABO16

Change TypeMaterial: lead screening frequency clarifiedcoding updates

Effective DateAug 8, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation and be prepared to provide additional documentation upon request for claims submission.

SourceLink

POLICY UPDATE CHANGES

Lead screening limited to children at increased risk and specified frequencies (monthly at 6, 9, 12 months; annually from age 2 to 6).

Added code 86481 to procedure code list.

Removed codes 86850, 87555, 87556, 0257U from code list.

Newborn–18population covered

2025-08-08plan effective date

6,9,12 mo; annually 2–6lead screening freq (at-risk)

CPCPLABO16policy id

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Pediatric Preventive Screening Reimbursement Criteria

Pediatric preventive screening reimbursement criteria

Reimbursement applies to specified preventive screening tests for newborns through age 18 with test- and risk-specific criteria.

Newborn screening: Newborn screening may be reimbursable when it follows all applicable federal and state law recommendations (panel).

Hyperbilirubinemia: Screening for hyperbilirubinemia in all newborns may be reimbursable.

Congenital hypothyroidism: Screening in all newborns utilizing serum thyroxine (T4) and/or thyroid-stimulating hormone (TSH) may be reimbursable.

Sickle cell disease: Screening for sickle cell disease in all newborns may be reimbursable.

ALL of the following

Frequencies for at‑risk children
- One test per month at 6, 9, and 12 months of age.
- One test per year from two years of age through six years of age.

Anemia screening: Screening for anemia with hemoglobin or hematocrit may be reimbursable in specified situations, including for individuals 4 months and older who are at risk for iron deficiency (see Note 2) and for all individuals at 12 months of age.

Tuberculosis screening: Tuberculosis screening may be reimbursable for individuals one month of age or older who are at increased risk (see Note 3).

Dyslipidemia screening: Screening with a fasting lipid or a non‑fasting non‑HDL‑C may be reimbursable annually for children and adolescents at increased risk and once during each of the age periods 9–11 years and at 17 years.

Sexual health screening: Screening for chlamydia, gonorrhea, and syphilis is addressed for sexually active adolescents and those at risk and is referenced to the related STI diagnostic policy (see related policies).

Example Procedure and Frequency Coding

Example procedure codes (not exhaustive)CPT

80061	80061
82247	82247
82465	82465
86481	86481

Lead screening frequency for at-risk children

At-risk populationBlood lead screening reimbursable only for individuals at increased risk for lead exposure (see Note 1).

Frequency — infancyOne test per month at 6, 9, and 12 months of age.

Frequency — toddler/preschoolOne test per year from two years of age through six years of age.

Policy referenceReimbursement information edited to limit lead screening to children at increased risk (Policy Update History 04/28/2025).

Documentation, Claims, and Review

Documentation Required

Documentation and Claim Review

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid code combinations from HIPAA-approved code sets. Claims should be coded per industry-standard coding guidelines (including but not limited to UB, AMA CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG guidance, CMS NCCI policy manual and table edits). Claims are subject to code edit protocols and claim review for benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers must furnish additional documentation to support the claim.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG as applicable)
Code according to industry standards (UB, AMA CPT guidance, CMS NCCI edits, etc.)
Claims are subject to code edit protocols and claim review against plan documents, provider contracts, medical policies, and coding software logic
Provide additional documentation upon request to substantiate services billed

Definitions and Risk Factors

Plan documents

Definition — plan documentsPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Governing orderIf a conflict arises between this Clinical Payment and Coding Policy and any plan document, the plan document will govern.

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

DiscretionBCBSOK may use reasonable discretion interpreting and applying this policy and has final discretionary authority as provided under applicable plan documents.

Lead exposure risk factors

Pre-1978 housingLiving in or spending time in a house or building built before 1978 is a lead exposure risk factor.