CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB015

Hepatitis testing (HBV and HCV) lab reimbursement criteria

BCBSNM clinical payment and coding policy describing reimbursable hepatitis B and C laboratory tests, population-based screening intervals, high-risk criteria, follow-up testing indications, and an associated procedure code list. Applies to lab reimbursement and coding; plan documents may further limit applicability.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCpcplab015 03 15 24

Policy CodePolicy CPCPLAB015

Change TypeRevised (material)

Effective DateMar 15, 2024

Next Review Date

Key ActionProviders must submit accurate documentation of services performed and use valid HIPAA-approved code combinations; additional documentation may be requested upon claim review.

SourceLink

POLICY UPDATE CHANGES

Revised #9 to expand nucleic acid testing allowance to include follow-up after positive antibody screening and one-time screening for perinatally exposed infants aged 2-17 months.

Added Hepatitis B header and new lifetime triple panel testing statement for individuals 18+; expanded and combined HBV criteria.

Added IgM anti-HBc testing to distinguish acute vs chronic infection and clarified other HBV follow-up tests.

2Viral hepatitis types covered (HBV, HCV)

13HBV high-risk criteria examples listed

14HCV one-time/post-exposure criteria listed

14Procedure codes listed

Policy summary and scope

BCBSNM's clinical payment and coding policy CPCPLAB015 (effective 2024-03-15, last reviewed 2024-02-01) defines laboratory reimbursement criteria for hepatitis B (HBV) and hepatitis C (HCV) testing. The policy aligns with CDC, AASLD/IDSA and other guideline sources for screening, follow-up NAT/viral-load testing, and population-based screening intervals, and specifies lifetime and periodic testing rules (for example, one-time lifetime antibody/triple-panel testing for adults 18+ and defined high-risk annual screening for HBV). Final coverage and reimbursement determinations remain subject to plan documents and provider contracts, and providers must submit accurate documentation and appropriate HIPAA-approved codes for claims adjudication.

Policy header

PayerBlue Cross Blue Shield - New Mexico

PolicyHepatitis testing (HBV and HCV) lab reimbursement criteria

Policy Code/NumberCPCPLAB015

Effective Date2024-03-15

Last Review2024-02-01

StatusCURRENT

Scope summaryBCBSNM clinical payment and coding policy describing reimbursable hepatitis B and C laboratory tests, population-based screening intervals, high-risk criteria, follow-up testing indications, and an associated procedure code list. Applies to lab reimbursement and coding; plan documents may further limit applicability.

Coverage criteria (when tests are reimbursable)

Hepatitis B - Lifetime and Annual Screening

Covered when the following criteria are met:

ALL of the following

For all individuals 18 years of age and older, triple panel testing (hepatitis B surface antigen [HBsAg], hepatitis B surface antibody [anti-HBs], total antibody to hepatitis B core antigen [anti-HBc]) once per lifetime may be reimbursable.

Hepatitis B - Annual HBV Infection Screening for Asymptomatic, Non-pregnant Individuals

Annual screening may be reimbursable for asymptomatic, non-pregnant individuals when ONE or more high-risk situations apply:

ONE of

HBsAg and anti-HBs for infants born from an HBsAg-positive individual

Procedure codes referenced

Procedure codes listed in policymixed

86704
86705
86706
86803
86804
87340
87341
87517
87520
87521

1–10 of 14

1/2

Billing Rule

Codes subject to claim edits and plan-specific applicability

Inclusion of a code in the policy does not guarantee coverage or reimbursement; claims remain subject to plan documents, provider contracts, medical policies, and code edit protocols.

86704
86705
86706
86803
86804
87340
87341
87517
87520
87521
87522
87902
G0472
G0499

Billing, documentation, and plan-specific requirements

Documentation Required

Submit accurate documentation and coding

Providers must submit accurate documentation of services performed and submit claims using valid HIPAA‑approved code combinations; additional documentation may be requested upon claim review.

Prior Authorization

Plan-specific reimbursement limits

Not all requirements apply to each product; providers should review applicable plan documents for eligible coverage — plan documents govern coverage and may require prior authorization per product terms.

May require prior authorization per product; review applicable plan documents.

Key terms

Definitions

Triple panel testing (HBV)Hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and total antibody to hepatitis B core antigen (anti-HBc).

Guideline and evidence sources

Policy references guideline sources including the CDC, AASLD‑IDSA guidance, USPSTF and WHO testing/treatment guidelines, and the reimbursement criteria are aligned with these sources as cited in the policy references.

Policy changes and timeline

02/01/2024revised

Revised #9 to expand nucleic acid testing allowance: clarified follow-up NAT after positive antibody screening and added one-time NAT screening for perinatally exposed infants aged 2-17 months; references revised.

02/01/2024revised

Added Hepatitis B header and new lifetime triple panel testing statement: For all individuals 18+ triple panel (HBsAg, anti-HBs, total anti-HBc) once per lifetime may be reimbursable; expanded and combined HBV high-risk criteria for annual screening (multiple new criteria added).

11/01/2023clarifiedLatest

Common operational questions

Note

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCpcplab015 03 15 24

Policy CodePolicy CPCPLAB015

Change TypeRevised (material)

Effective DateMar 15, 2024

Next Review Date

Key ActionProviders must submit accurate documentation of services performed and use valid HIPAA-approved code combinations; additional documentation may be requested upon claim review.

SourceLink

On This Page

Triple panel testing (HBsAg, anti-HBs, anti-HBc) when one of the high-risk situations is met

High-risk situations (examples listed)

Born in or recently traveled to geographic regions with HBV prevalence >= 2% (See Note 1)
U.S.-born not vaccinated as infants whose parents were born in regions with HBV prevalence >= 8% (See Note 1)
History of incarceration
Infected with HIV
History of sexually transmitted infections or multiple sex partners
Men who have sex with men
Household contacts, needle-sharing contacts, and sex partners of HBV-infected individuals
Injection-drug users
Active hepatitis C infection or history of hepatitis C infection
Elevated liver enzymes
On long-term hemodialysis treatment
Diabetes
Healthcare and public safety workers exposed to blood or body fluids

Hepatitis B - Follow-up and Special Indications

Additional reimbursable testing in specific situations:

ALL of the following

For individuals who test positive for anti-HBc, follow-up IgM antibody to anti-HBc (IgM anti-HBc) testing to distinguish between an acute or chronic infection may be reimbursable.
For confirmation of seroconversion after hepatitis B vaccination, anti-HBs testing may be reimbursable.
For individuals who test positive for HBV by initial antibody screening and who will undergo immunosuppressive drug therapy, HBV DNA testing may be reimbursable.

Hepatitis C - Lifetime and One-time/Post-exposure Screening

Covered when the following criteria are met:

For all individuals 18 years of age and older, antibody testing for HCV infection once per lifetime may be reimbursable.

One-time, post-exposure antibody testing reimbursable for individuals with any of:

Used illicit intranasal or injectable drugs
Received clotting factor concentrates produced before 1987
History of hemodialysis
Evidence of liver disease (clinical presentation, persistently abnormal ALT, or abnormal LFTs)
Infected with HIV
Received an organ transplant before July 1992
Received a blood transfusion or blood component before July 1992
Notified that they received blood from a donor who later tested positive for HCV
History of incarceration
Received a tattoo in an unregulated setting
Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV-positive blood
Children born to HCV-positive individual
Current sexual partners of HCV-infected persons

Hepatitis C - Routine Periodic Antibody Testing for Ongoing Risk

Routine periodic antibody testing may be reimbursable while ongoing risk factors persist:

ANY of the following

Individuals who currently inject drugs and share needles, syringes, or other drug preparation equipment
Individuals who are receiving ongoing hemodialysis
Individuals engaging in high-risk sexual behavior

Hepatitis C - Nucleic Acid and Viral Load Testing

Nucleic acid testing (NAT) and quantitative viral load testing may be reimbursable in these situations:

ANY of the following

Nucleic acid testing as follow-up for individuals who test positive by initial antibody screening to differentiate active infection vs resolved infection
One-time NAT screening for perinatally exposed infants aged 2-17 months2-17 months
HCV genotype testing one time prior to initiation of direct antiviral (DAA) treatment to guide regimen selection
Viral load (quantitative NAT) timing around DAA therapy
- Prior to initiation of DAA therapy
- After 4 weeks of DAA therapy
- At the end of treatment
- 12 weeks after completion of treatment
- 24 weeks after completion of treatment
- 48 weeks after completion of treatment

Thresholds

HBV geographic prevalence threshold>= 2% (regions where born/recent travel) and >= 8% (parents' region for US-born not vaccinated as infants)

Perinatal NAT screening age2-17 months

Added IgM anti-HBc testing to distinguish acute vs chronic infection and clarified other HBV follow-up tests (including anti-HBs for seroconversion confirmation and HBV DNA prior to immunosuppressive therapy); language edited for clarity and references revised.

Has material change: true — headline changes include expansion of nucleic acid testing allowance to include follow-up after positive antibody screening and a one-time NAT screening for perinatally exposed infants aged 2-17 months; addition of a lifetime triple panel testing statement for adults 18+; and addition of IgM anti-HBc testing to help distinguish acute versus chronic HBV infection.