CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLABO53

Hemolytic Streptococcus Testing Reimbursement and Coding Policy

This Clinical Payment and Coding Policy defines reimbursement criteria and exclusions for laboratory testing to detect hemolytic streptococcal infections for Blue Cross and Blue Shield of Illinois members and applies to providers submitting claims to BCBSIL.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyHemolytic Streptococcus Testing Reimbursement and Coding Policy

Policy CodePolicy CPCPLABO53

Change TypeNew policy (Version 1.0)

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit accurate documentation and claims using valid HIPAA code sets; BCBSIL may request additional documentation and will apply this policy at its discretion.

SourceLink

POLICY UPDATE CHANGES

New policy establishing reimbursement criteria and exclusions for hemolytic streptococcus testing.

1.0policy version

2026-01-01effective date

2025-09-25approval date

≥12procedure codes listed

Reimbursement and Exclusion Criteria

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyHemolytic Streptococcus Testing Reimbursement and Coding Policy

Policy CodePolicy CPCPLABO53

Change TypeNew policy (Version 1.0)

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit accurate documentation and claims using valid HIPAA code sets; BCBSIL may request additional documentation and will apply this policy at its discretion.

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.

Reimbursement and exclusion criteria

Circumstances when streptococcal testing is reimbursable or specifically excluded:

ALL of the following

Reimbursable throat testing (one of)
- Throat bacterial culture for detection of streptococcal respiratory infection when the individual has a modified Centor score >= 3
- Throat bacterial culture when the individual is suspected of having bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea)
- Throat bacterial culture following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent
Skin or soft tissue bacterial culture for suspected streptococcal infection (from skin swab or pus)
Serologic and special testing (one of)
- Anti-streptolysin O immunoassay for suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN)
- Hyaluronidase activity testing or anti-hyaluronidase immunoassay for suspected ARF or PSGN
- Streptokinase activity testing or anti-streptokinase immunoassay for suspected ARF or PSGN

ALL of the following

Not reimbursable (any of)
- Throat bacterial culture for suspected viral pharyngitis is not reimbursable
- RADT is not reimbursable as a follow-up test after a bacterial culture or a nucleic acid test (NAAT)
- RADT is not reimbursable as screening in asymptomatic patients (except for asymptomatic children under age 3 with a mitigating circumstance, e.g., a symptomatic household member)
- Serological titer testing is not reimbursable except as described for suspected ARF or PSGN
- Simultaneous ordering of both a direct probe and an amplification probe for the same organism in a single encounter is not reimbursable

ALL of the following

Note: Modified Centor criteria includes tonsillar exudates; tender anterior cervical lymphadenopathy; fever; and absence of cough, with each criterion worth one point

ALL of the following

Inclusion of a code in the listed procedure codes does not guarantee coverage or reimbursement eligibility
Billing rule

ALL of the following

Exception to RADT follow-up restriction: asymptomatic children under age 3 years with a mitigating circumstance (including a symptomatic family member) may be considered
Exception detail

ALL of the following

Testing for serologic titers or specific enzyme/activity immunoassays (anti-streptolysin O, hyaluronidase, streptokinase) may be reimbursable only in the clinical context of suspected ARF or PSGN; otherwise these are not reimbursable
Application

Procedure Codes and Coding Rules

Example listed procedure codesCPT

86060	Antistreptolysin O (ASO) titer
86063	Antistreptococcal antibody titer, other
86215	Hyaluronidase assay or related
86317	Streptokinase activity/assay
86318	Other serologic test
86581	Probe or antigen test (rapid)
87070	Culture, throat
87071	Culture, wound/skin
87077	Culture for streptococcus
87081	Culture, anaerobic/other

1–10 of 11

1/2

Modified Centor score threshold

Modified Centor score threshold>= 3 — Throat bacterial culture from a throat swab may be reimbursable when the individual has a modified Centor criteria score of 3 or greater.

Other reimbursable throat culture indicationReimbursable when suspected bacterial pharyngitis without viral features (e.g., cough, oral ulcers, rhinorrhea).

Reimbursable after negative RADT in symptomatic youthThroat culture reimbursable following a negative RADT in a symptomatic child or adolescent.

RADT follow-up restriction

General restriction on RADT follow-upRADT is not reimbursable as a follow‑up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection.

Screening restrictionRADT is not reimbursable as a screening method in an asymptomatic patient.

Exception for young childrenException: RADT may be reimbursable for asymptomatic children under age 3 with a mitigating circumstance (including a symptomatic family member).

Documentation and Provider Requirements

Documentation Required

Documentation, coding, and BCBSIL review

Providers must submit accurate documentation of services performed and file claims using valid HIPAA-approved code sets and appropriate industry-standard coding guidelines. BCBSIL may request additional documentation and exercises discretion in interpreting and applying this policy to services delivered in a particular case.

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 (e.g., Uniform Billing Editor, AMA CPT guidance, CMS NCCI edits).
Provide any additional documentation if requested by BCBSIL to support medical necessity or correct coding.

OpenPayer

Hemolytic Streptococcus Testing Reimbursement and Coding Policy

Reimbursement and Exclusion Criteria

Procedure Codes and Coding Rules

Documentation and Provider Requirements

Definitions and Scoring Criteria