CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO27

Testing for Diagnosis of Active or Latent Tuberculosis

This policy governs laboratory testing and reimbursement criteria for diagnosis and screening of active and latent tuberculosis (TB) for Blue Cross Blue Shield - New Mexico members and providers submitting claims to the Plan.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLABO27

Change TypeAdded NAATprocedure code list updated

Effective DateSep 26, 2025

Next Review Date

Key ActionReview plan documents for product-specific coverage and prior authorization requirements before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M. tuberculosis, and M. avium complex was added to the reimbursable tests.

Codes 87564 and 0574U were added to the procedure code list.

Codes 87149, 87550, 87555, and 87560 were removed from the procedure code list.

>10references cited

~20procedure/test codes

CD4 <100urine LAM threshold

3 monthsrepeat DST trigger

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Reimbursable testing criteria

Covered or potentially reimbursable tests when the criteria below are met:

Latent TB screening: Interferon gamma release assay (IGRA) may be reimbursable for diagnosis or screening of latent tuberculosis (TB) infection.

Used for individuals at risk or when screening is required by law

Suspected active TB testing: For all suspected TB infections, the following tests may be reimbursable: acid-fast bacilli (AFB) smear/stain; culture and culture-based drug susceptibility testing of Mycobacteria spp.; qualitative nucleic acid amplification testing (NAAT) for Mycobacteria.

Molecular-based DST may be reimbursable for sputum AFB smear-positive or NAAT-positive individuals when resistance risk factors are present

Repeat drug susceptibility testing may be reimbursable if sputum cultures remain positive after 3 months of treatment or when bacteriological reversion from negative to positive occurs.3 months

Extrapulmonary fluid testing: For suspected extrapulmonary TB involving pleural effusion, pericardial effusion, ascites, or CSF, cell counts, protein, glucose, and lactate dehydrogenase (LDH) of the relevant fluids may be reimbursable.

Urine LAM testing: In HIV-infected individuals with CD4 <100 cells/microL who have signs and symptoms of TB, urine-based lipoarabinomannan (LAM) testing may be reimbursable.CD4 <100 cells/microL

Not reimbursable

Explicitly not reimbursable tests:

Excluded for active TB: Interferon gamma release assay (IGRA) is not reimbursable for individuals with active tuberculosis.

Quantitative NAAT not reimbursable: Quantitative nucleic acid testing for Mycobacterium species, M. tuberculosis, and M. avium complex is not reimbursable.

Fluid biomarker panels not reimbursable: Testing of adenosine deaminase (ADA) and interferon-gamma levels in cerebrospinal, pleural, peritoneal, pericardial, and other fluids, and testing of serum protein biomarker panels for extrapulmonary TB detection, are not reimbursable.

Testing of fluid biomarkers including adenosine deaminase (ADA) and interferon-gamma in cerebrospinal, pleural, peritoneal, pericardial, and other body fluids is specifically identified as not reimbursable for diagnosis of extrapulmonary tuberculosis. Providers should not expect payment for requests to measure ADA or interferon-gamma levels in these fluids for the purpose of diagnosing extrapulmonary TB.

The policy also excludes testing of serum protein biomarkers or panels for detection of extrapulmonary TB. When evaluating suspected extrapulmonary disease, use of reimbursable standard diagnostic modalities (e.g., microbiologic culture, AFB smear, or NAAT where indicated) is preferred; fluid biomarker panels and the ADA/IFN-gamma assays listed above are considered non-covered diagnostic methods under this policy.

Interferon gamma release assay (IGRA) is explicitly listed as not reimbursable when used for individuals with active tuberculosis. Claims for IGRA performed to diagnose or manage active TB should be expected to be denied under this policy.

Procedure and Test Codes

Procedure/Test Codes (listed)mixed

81099
82945
83520
83615
84157
84311
86480
86481
87070
87077

1–10 of 18

1/2

Procedure/Test Codes (listed) - coverage status summarymixed

No codes listed

inv-06: CD4 count threshold for urine LAM testing

CD4 count threshold< 100 cells/microL

ContextApplies to HIV-infected individuals with signs and symptoms of tuberculosis for urine LAM testing

SpecimenUrine-based detection of LAM (lipoarabinomannan)

inv-07: Sputum persistence threshold for repeat DST

ThresholdSputum cultures remain positive after 3 months of treatment

Alternate indicationBacteriological reversion from negative to positive may also prompt repeat DST

Applies toIndividuals undergoing TB treatment where repeat drug susceptibility testing is considered

Provider Actions, Documentation & Billing

Prior Authorization

Prior Authorization Required (when applicable)

Check the member's specific plan documents (Certificate of Benefits, benefit booklet, Summary Plan Description, or other coverage document) before ordering services. Prior authorization and other utilization management requirements vary by product; some Blue Cross Blue Shield - New Mexico products may require prior authorization for laboratory testing or have network/reimbursement restrictions.

Requirements vary by product — verify member's plan documents for prior authorization and coverage rules.
Prior authorization may be required for certain lab tests or reimbursement under some products.

Documentation Required

Provider Documentation and Medical Necessity

Providers must submit accurate, complete clinical documentation when requested. BCBSNM may ask for additional records to support medical necessity, coverage, or coding. Failure to provide requested documentation can lead to claim denial or recoupment.

Retain and provide clinical notes, test results, and ordering rationale upon request.
Respond promptly to documentation requests to avoid payment delays or denials.

Billing Rule

Coding Accuracy and Claim Review

Use valid HIPAA-approved code sets and industry-standard coding guidelines when submitting claims. Claims are subject to code edit protocols and review against provider contracts, benefit coverage, medical policies, and clinical payment and coding policies.

Bill with correct CPT, HCPCS, ICD-10, NDC, and other applicable codes.
Claims may be edited for National Correct Coding Initiative (NCCI) and other CMS-based rules.

Documentation Required

Provider Action: Submit Accurate Documentation and Verify Coverage

Providers are expected to submit claims using valid code combinations and may be asked to supply additional documentation. Review plan-specific lab management and reimbursement criteria (including tests and indications for TB-related testing) to ensure services billed are eligible under the member's product.

Submit supporting documentation for laboratory testing indications (e.g., IGRA for TB screening, culture/NAAT for suspected TB, drug susceptibility testing criteria, fluid analyses for suspected extrapulmonary TB).
If services are not eligible under the member's plan, claims may be denied per plan document or provider contract.

Background and Rationale

This policy recognizes several laboratory modalities used in the evaluation of tuberculosis. Interferon gamma release assays (IGRAs) are intended for diagnosis or screening of latent TB infection rather than active disease. Microbiologic methods including acid-fast bacilli (AFB) smear and culture with culture-based drug susceptibility testing (DST) remain central for diagnosing active TB and guiding therapy. Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp. is included as a reimbursable molecular diagnostic for suspected active infection where indicated. Molecular-based DST may be appropriate when resistance risk factors are present or when initial sputum AFB smear or NAAT is positive.

The policy also distinguishes tests that are not reimbursable: quantitative nucleic acid testing for Mycobacterium spp. and certain biomarker assays (including ADA and interferon-gamma in body fluids) are excluded. Providers should select diagnostic modalities aligned with the policy’s reimbursable methods and avoid non-covered quantitative NAAT or fluid biomarker testing when evaluating TB.

Definitions and Abbreviations

inv-13: IGRA

DefinitionInterferon gamma release assay (IGRA) used to diagnose or screen for latent tuberculosis infection

Coverage noteIGRA may be reimbursable for latent TB screening; IGRA is not reimbursable for individuals with active tuberculosis

Use caseUsed for individuals at risk or when screening is required by law

inv-14: NAAT

DefinitionQualitative nucleic acid amplification testing (NAAT) for Mycobacteria species including M. tuberculosis and M. avium complex

Coverage noteNAAT is listed among reimbursable tests for suspected TB infections; document update replaced prior direct probe language with NAAT

Applies toUsed for detection of Mycobacteria in respiratory specimens; NAAT-positive sputum may trigger molecular-based DST when resistance risk factors present

inv-15: LAM

DefinitionLipoarabinomannan (LAM) urine assay for detection of mycobacterial cell wall glycolipid in HIV-infected individuals

IndicationMay be reimbursable in HIV-infected individuals with CD4 <100 cells/microL who have signs and symptoms of tuberculosis

SpecimenUrine-based detection

OpenPayer

Testing for Diagnosis of Active or Latent Tuberculosis

Coverage Criteria for TB Testing

Procedure and Test Codes

Provider Actions, Documentation & Billing

Background and Rationale

Definitions and Abbreviations