CurrentBlue Cross Blue Shield - TexasPolicy CPCPLAB071

Colorectal Cancer Screening

This clinical payment and coding policy describes Blue Cross Blue Shield of Texas reimbursement stance and lab management criteria for colorectal cancer screening tests and which tests are eligible for reimbursement for plan members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyColorectal Cancer Screening

Policy CodePolicy CPCPLAB071

Change TypeMaterial additions and clarifications (new reimbursable FIT‑DNA entry, exclusions, and procedure codes)

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit accurate documentation and claims using valid code combinations; claims may be reviewed and require additional documentation.

SourceLink

POLICY UPDATE CHANGES

Cologuard Plus™ was added as a reimbursable FIT-DNA test once every 3 years.

Screening using cell-free DNA techniques (e.g., Guardant Shield™) was added to the list of not reimbursable screening techniques.

Procedure codes 0464U and 0537U were added to the policy code list.

The document was updated with a literature review.

45-75age range

3 yrsFIT-DNA frequency

over 75not reimbursable age

2new procedure codes

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyColorectal Cancer Screening

Policy CodePolicy CPCPLAB071

Change TypeMaterial additions and clarifications (new reimbursable FIT‑DNA entry, exclusions, and procedure codes)

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit accurate documentation and claims using valid code combinations; claims may be reviewed and require additional documentation.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Reimbursement Criteria

Primary coverage criteria

Reimbursement criteria for asymptomatic individuals:

Covered when ALL of the following are met:

ALL of the following

Age 45-75 years (average risk, asymptomatic).
Tests allowed (annual)
- Fecal immunochemical test (FIT) — preferred; frequency: annual.
- Guaiac fecal occult blood test (gFOBT); frequency: annual.

ALL of the following

FIT-DNA (Cologuard™ or Cologuard Plus™).
Frequency: once every 3 years.

>75 years — average-risk, asymptomatic individuals: colorectal cancer screening is not reimbursable.

Techniques not reimbursable

Methylated Septin 9 (ColoVantage) — not reimbursable.
Screening for anal cytologic abnormalities (anal pap smear) — not reimbursable.
Screening for anal HPV infection — not reimbursable.
Screening using cell-free DNA techniques (e.g., Guardant Shield™) — not reimbursable.

Procedure Codes and Frequency

Listed procedure codesCPT

0464U	Added to procedure code list (policy does not guarantee coverage by inclusion).
0537U	Added to procedure code list (policy does not guarantee coverage by inclusion).

FIT‑DNA frequency

Allowed testFIT-DNA (Cologuard™, Cologuard Plus™)

FrequencyOnce every 3 years

PopulationAverage-risk, asymptomatic individuals

Coverage noteMay be reimbursable when criteria met

FIT / gFOBT frequency

Allowed testsFecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT)

FrequencyAnnual

Documentation, Billing, and Claim Submission

Documentation Required

Documentation and claim submission requirements

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 are subject to code edit protocols and claim review and may require submission of additional documentation upon request.

Submit claims using valid code combinations from HIPAA-approved code sets (e.g., CPT, HCPCS, ICD-10).
Code claims according to industry standard coding guidelines (Uniform Billing, AMA CPT, CMS NCCI edits).
Be prepared to provide additional documentation upon request for claim review.

Test Definitions and Exclusions

Multitarget stool DNA test

Test examplesCologuard™, Cologuard Plus™ (multitarget stool DNA tests)

FrequencyOnce every 3 years

PopulationAverage-risk, asymptomatic individuals

Coverage noteMay be reimbursable when criteria met

Fecal immunochemical test

Test nameFecal immunochemical test (FIT)

Preferred statusPreferred test for annual screening