CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLAB063

Identification of Microorganisms Using Nucleic Acid Probes

Reimbursement and coding policy describing when nucleic acid probe-based tests for microorganism identification (direct probe, amplified probe, quantification) may be reimbursable for Blue Cross and Blue Shield of Illinois products; applies to providers submitting claims to BCBSIL and varies by product/plan document.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyIdentification of Microorganisms Using Nucleic Acid Probes

Policy CodePolicy CPCPLAB063

Change TypeNew policy

Effective Date01/01/2026

Next Review Date

Key ActionUpon request, provider should submit any additional documentation; claims are subject to review against plan documents, provider contracts, medical policies, clinical payment and coding policies and code edit protocols.

SourceLink

POLICY UPDATE CHANGES

New policy.

1.0policy version

01/01/2026plan effective date

27 codesprocedure codes listed

simultaneousnot reimbursable per encounter

Reimbursement by Organism and Test Type

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 status by organism and test type

Table summarizes reimbursement status by organism and probe method; only individual probes are reviewed and panels are beyond scope.

Bartonella henselae or quintana: Direct probe — not specified; Amplified probe — 87471 (MBR); Quantification — 87472 (INR).

Chlamydia pneumoniae: Direct probe — 87485 (INR); Amplified probe — 87486 (MBR); Quantification — 87487 (INR).

Clostridium difficile: Direct probe — not specified; Amplified probe — 87493 (MBR); Quantification — not specified.

Cytomegalovirus: Direct probe — 87495 (INR); Amplified probe — 87496 (MBR); Quantification — 87497 (MBR).

Enterovirus: Direct probe — not specified; Amplified probe — 87498 (MBR); Quantification — not specified.

Enterococcus, vancomycin-resistant (e.g., vanA, vanB): Direct probe — not specified; Amplified probe — 87500 (MBR); Quantification — not specified.

Hepatitis G: Direct probe — 87525 (INR); Amplified probe — 87526 (INR); Quantification — 87527 (INR).

Herpes-virus-6: Direct probe — 87531 (INR); Amplified probe — 87532 (INR); Quantification — 87533 (MBR).

Legionella pneumophila: Direct probe — 87540 (INR); Amplified probe — 87541 (MBR); Quantification — 87542 (INR).

Mycoplasma pneumoniae: Direct probe — 87580 (INR); Amplified probe — 87581 (MBR); Quantification — 87582 (INR).

Orthopoxvirus: Direct probe — not specified; Amplified probe — 87593 (MBR); Quantification — not specified.

Respiratory syncytial virus: Direct probe — not specified; Amplified probe — 87634 (MBR); Quantification — not specified.

Staphylococcus aureus: Probe type 1 — not specified; Probe type 2 — 87640 (MBR); Probe type 3 — not specified.

Staphylococcus aureus, methicillin resistant: Probe type 1 — not specified; Probe type 2 — 87641 (MBR); Probe type 3 — not specified.

Procedure Codes and Status

Listed procedure codesCPT

87471	87471
87472	87472
87485	87485
87486	87486
87487	87487
87493	87493
87495	87495
87496	87496
87497	87497
87498	87498

1–10 of 28

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Reimbursable vs Not Reimbursable (Status Indicators)

MBR (May Be Reimbursable)Indicates the test may be reimbursable when submitted with appropriate coding and documentation per plan provisions.

INR (Not Reimbursable)Indicates the test is not reimbursable under this policy and should not be billed for reimbursement.

Scope of ApplicationApplies to individual nucleic acid probe tests (direct probe, amplified probe, quantification); panels are beyond the scope of this policy.

Status Indicator Definitions

"MBR" — May Be Reimbursable

Definition"MBR" indicates that the test may be reimbursable.

Applicable TestsUsed in the policy table to denote individual nucleic acid identification tests (direct, amplified, quantification).

ConditionsReimbursement is subject to member plan documents, provider contract terms, coding accuracy, and any applicable code edit protocols or medical policies.

"INR" — Not Reimbursable

Definition"INR" indicates that the test is not reimbursable.

Billing GuidanceDo not bill for procedures designated as INR under this policy; claims for INR-coded tests are not reimbursable per the table.

Scope NoteINR designations apply to individual probes only; panel testing is not evaluated in this policy.

Billing Rules and Documentation Requirements

Documentation Required

Documentation and Claim Review

Providers are responsible for submission of accurate documentation of services performed. Upon request, providers must submit additional documentation to support medical necessity and coding. Claims are subject to review against plan documents, provider contract language, medical policies, clinical payment and coding policies, and code-edit protocols. Blue Cross and Blue Shield of Illinois may use reasonable discretion when interpreting and applying this policy; plan documents and provider contracts govern in case of conflict.

Providers must submit claims using valid HIPAA code sets (CPT, HCPCS, ICD-10, NDC, etc.).
Claims are subject to code edit protocols and claim review, including plan benefit terms and provider contract language.
Upon request, providers should promptly provide any additional documentation to support the claim.

Billing Rule

Billing Rule - Simultaneous Tests

Do not bill both an amplified probe and a quantification for the same organism during a single encounter; simultaneous ordering of any combination of amplified probe and quantification for the same organism in one encounter is not reimbursable.

Applies to pairs of CPT codes where one is an amplified probe and the other is a quantification for the same organism.
If both tests are performed, submit documentation explaining the clinical rationale — reimbursement is not guaranteed and may be denied per this rule.