CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB022

Prenatal Screening for Fetal Aneuploidy

This policy sets Blue Cross Blue Shield - Oklahoma's reimbursement and coding positions for laboratory prenatal screening tests for fetal aneuploidy and applies to providers submitting claims under BCBSOK plans; plan documents and provider contracts may govern in case of conflict.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrenatal Screening for Fetal Aneuploidy

Policy CodePolicy CPCPLAB022

Change TypeNo material change

Effective DateNov 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

11/01/2023plan effective

~23listed codes

5exclusions

Prenatal Aneuploidy Screening Coverage Criteria

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ALL of the following

Confirmatory diagnostic testing
- Confirmatory testing of equivocal and positive screening results via Chorionic Villus Sampling (CVS) or Amniocentesis should be offered and may be reimbursable for women wishing to pursue additional testing.
Exclusions - specific test
- Use of the 'penta' screen (hCG, AFP, uE3, DIA with NT, and hyperglycosylated hCG) to detect fetal aneuploidy is not reimbursable.
Exclusions - non-reimbursable screening conditions
- Parallel or simultaneous testing with multiple screening methodologies for fetal aneuploidy.
- Screening of women with multiple gestation pregnancies with any testing other than nuchal translucency and/or subsequent diagnostic testing via Chorionic Villus Sampling (CVS) or Amniocentesis due to the risk of high false positive results.
- Repeat screening for women with negative screening results.
- Egg donor pregnancies.
- Screening for determination of fetal sex.

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Documentation and Claim Review Requirements

Documentation Required

Documentation, coding and claim review — submit accurate records and respond to audit requests

Providers are responsible for submitting accurate documentation and using valid HIPAA-approved code combinations; claims are subject to code edit protocols and review against benefit documents, provider contracts, medical policies, and coding rules. Upon request, providers must furnish any additional documentation to support the claim.

Submit claims using valid code combinations from HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG, etc.).
Code claims according to industry-standard coding guidelines (AMA CPT, UB Editor, CMS NCCI/CCI edits, CPT Assistant).
Be prepared for claim review and audits; provide additional documentation upon request.
Note that plan documents or provider contracts govern if they conflict with this policy.

Definitions and Test Notes

inv-04: Confirmatory testing of equivocal or positive results via CVS or Amniocentesis — definition/clarification entry.

DefinitionConfirmatory diagnostic testing of equivocal or positive prenatal screening results via Chorionic Villus Sampling (CVS) or Amniocentesis.

When offeredShould be offered to women with equivocal or positive screening results who wish to pursue additional testing.

Reimbursement stanceMay be reimbursable when performed for women pursuing additional diagnostic testing following an equivocal or positive screen.

Relation to coverage documentsCoverage and applicability depend on plan documents; not all requirements apply to every product.

Documentation requirementProviders must submit accurate documentation and may be asked to provide additional records upon request to support claims.

inv-05: The 'penta' screen — not reimbursable; present as definition/flag.

Definition'Penta' screen: combination screen described as hCG, AFP, uE3, DIA with NT, and hyperglycosylated hCG.

Reimbursement stanceUse of the 'penta' screen to detect fetal aneuploidy is not reimbursable.

ContextListed as an explicit excluded screening methodology under the prenatal aneuploidy screening criteria.

Provider actionProviders should not bill for the 'penta' screen for fetal aneuploidy as reimbursable under this policy.