CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO26

Fecal Calprotectin Testing in Adults

Reimbursement criteria and coding guidance for fecal calprotectin testing in individuals 18 years and older under Blue Cross Blue Shield of Texas products; providers should review plan documents for product-specific applicability.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyFecal Calprotectin Testing in Adults

Policy CodePolicy CPCPLABO26

Change TypeAge applicability addedcontent migrated to CPCPLABO3S

Effective DateOct 3, 2025

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved code sets when filing claims; claims are subject to review and plan documents govern if conflicts arise.

SourceLink

POLICY UPDATE CHANGES

This policy is specific to individuals 18 years of age or older; criteria do not apply to individuals less than 18 years of age.

Statements were revised to remove leading statements 'For individuals 18 years of age or older.' and references were updated following literature review.

Document archived and information moved to CPCPLABO3S Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease.

18+age applicability

3reimbursement rule bullets

CPCPLABO26policy id

Multiplereferences

Fecal Calprotectin Coverage Criteria (Adults)

Adult fecal calprotectin coverage criteria

Reimbursement criteria for fecal calprotectin testing (adults 18+):

ALL of the following

ALL of the following
- Individual is 18 years of age or older
  Criteria do not apply to individuals less than 18 years of age

ANY of the following

ALL of the following
- Fecal calprotectin testing for the differential diagnosis between noninflammatory gastrointestinal disease (e.g., IBS) and inflammatory gastrointestinal disease (IBD) may be reimbursable.
ALL of the following

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyFecal Calprotectin Testing in Adults

Policy CodePolicy CPCPLABO26

Change TypeAge applicability addedcontent migrated to CPCPLABO3S

Effective DateOct 3, 2025

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved code sets when filing claims; claims are subject to review and plan documents govern if conflicts arise.

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.

Documentation, Claims Submission, and Policy Interpretation

Documentation Required

Documentation and Claims Submission — Provider Requirements

Providers are responsible for submitting accurate documentation of services performed and for coding and billing claims using valid, HIPAA–approved code sets. Claims should be coded according to industry standards and guidance (for example, Uniform Billing Editor, AMA CPT, CPT Assistant, HCPCS, ICD‑10‑CM/PCS, DRG guidelines, NDCs, CMS National Correct Coding Initiative policy manual, CCI edits, and other CMS guidance). Claims are subject to automated and manual code‑edit protocols and may be reviewed against plan benefit terms, provider contract language, medical policies, and clinical payment and coding policies. Upon request, providers should supply any additional documentation to support the claim.

Submit accurate documentation of services performed.
Use valid HIPAA‑approved code sets and industry coding guidance (CPT, HCPCS, ICD‑10, NDC, DRG, CCI/NCCI guidance, etc.).
Claims are subject to code‑edit protocols and automated/manual review.
Claims may be reviewed against plan documents, provider contracts, medical policies, and clinical payment and coding policies.
Provide additional documentation upon request.

Note

Policy Interpretation and Precedence

Blue Cross and Blue Shield of Texas may use reasonable discretion in interpreting and applying this policy. Where conflicts arise, the following precedence applies: plan documents (for example, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions) govern member entitlement to Covered Services; provider contracts govern where they apply. BCBSTX retains final discretionary authority for interpretation and application of this policy to the extent allowed by applicable plan documents.

Plan documents govern conflicts regarding member entitlement to Covered Services.
Provider contracts take precedence where applicable.
BCBSTX may exercise reasonable discretion in policy interpretation and application.

Definitions and Clinical Use

Differential diagnosis (usage note)

PurposeUse fecal calprotectin testing to aid in the differential diagnosis between noninflammatory gastrointestinal disease (e.g., IBS) and inflammatory gastrointestinal disease (IBD)

When reimbursableTesting for this differential diagnosis may be reimbursable when performed for distinguishing noninflammatory vs inflammatory GI disease

LimitationsTesting for other indications not described in the policy is not reimbursable

Monitoring and response assessment (usage note)

PurposeFecal calprotectin testing to assess response to therapy, detect relapse, or monitor gastrointestinal conditions such as inflammatory bowel disease (IBD)

When reimbursableTesting for monitoring response, relapse detection, or ongoing IBD monitoring may be reimbursable

Related guidanceMonitoring and response assessment are specifically called out as reimbursable uses in the adult reimbursement criteria

OpenPayer

Fecal Calprotectin Testing in Adults

Fecal Calprotectin Coverage Criteria (Adults)

Procedure Coding and Age Applicability

Documentation, Claims Submission, and Policy Interpretation

Definitions and Clinical Use