CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

β - Hemolytic Streptococcus Testing

Coverage and reimbursement guidance for laboratory testing related to streptococcal infections (including rapid antigen, culture, nucleic acid testing, and serologic assays) for Blue Cross Blue Shield - New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policyβ - Hemolytic Streptococcus Testing

Policy CodePolicy N/A

Change TypeAdded CPT codecoverage clarifications

Effective DateNov 19, 2024

Next Review DateN/A

Key ActionDocument clinical indication (e.g., suspected ARF or PSGN) when ordering serologic testing to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added new CPT code 86581 effective 01/01/2025.

Updated reimbursement language to include nucleic acid testing as a type of follow-up test after initial culture or nucleic acid test.

For suspected acute rheumatic fever or post-streptococcal glomerulonephritis, certain serologic tests may be reimbursable (ASO, hyaluronidase, streptokinase assays and titers).

86581New CPT code added

03/01/2024ARF/PSGN reimbursement added

11/19/2024Policy effective

10/30/2024Last review

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policyβ - Hemolytic Streptococcus Testing

Policy CodePolicy N/A

Change TypeAdded CPT codecoverage clarifications

Effective DateNov 19, 2024

Next Review DateN/A

Key ActionDocument clinical indication (e.g., suspected ARF or PSGN) when ordering serologic testing to support reimbursement.

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.

Coverage and Reimbursement Criteria

Reimbursable serology in ARF/PSGN

Covered when specific clinical indications are met:

Serology for ARF/PSGN: For individuals with suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), the following serologic tests may be reimbursable: serological titer testing; anti-streptolysin O (ASO) immunoassay; hyaluronidase activity or anti-hyaluronidase immunoassay; streptokinase activity or anti-streptokinase immunoassay.

Added 03/01/2024

Follow-up testing reimbursement

Follow-up testing:

Follow-up testing types: A follow-up test may be reimbursed for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection; policy language was updated to explicitly include nucleic acid testing.

Reimbursement Information #6.a updated

For purposes of reimbursement, serologic testing for group A Streptococcus (including anti-streptolysin O immunoassay, hyaluronidase activity or anti-hyaluronidase immunoassay, and streptokinase activity or anti-streptokinase immunoassay) is covered only in the specific clinical situations described in this policy. Serologic titer testing and the listed immunoassays may be reimbursable for individuals with suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), and a follow-up serologic test may be reimbursed when performed after an initial bacterial culture test or a nucleic acid test for a streptococcal infection. Outside of these described indications and follow-up scenarios, serologic testing is not eligible for reimbursement.

Serologic testing (ASO, hyaluronidase, streptokinase assays) is not reimbursable when performed outside the indications and follow-up situations specifically described in this policy. Claims for these assays submitted for other clinical circumstances risk denial.

Specific Covered Indications

Suspected acute rheumatic fever (ARF)

Covered when the clinical presentation suggests acute rheumatic fever:

ARF — reimbursable serologic tests: When acute rheumatic fever (ARF) is suspected, anti-streptolysin O (ASO) immunoassay, hyaluronidase activity or anti-hyaluronidase immunoassay, and streptokinase activity or anti-streptokinase immunoassay may be reimbursable.

Added 03/01/2024

Post-streptococcal glomerulonephritis (PSGN)

Covered when the clinical presentation suggests post-streptococcal glomerulonephritis:

PSGN — reimbursable serologic tests: When post-streptococcal glomerulonephritis (PSGN) is suspected, anti-streptolysin O (ASO) immunoassay, hyaluronidase activity or anti-hyaluronidase immunoassay, and streptokinase activity or anti-streptokinase immunoassay may be reimbursable.

Added 03/01/2024

Codes and Billing

Covered CPT Codes (added)CPTCovered

86581

New CPT code added effective 01/01/2025

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization / New CPT Code

New CPT code added — verify prior authorization requirements before billing. A new CPT code (86581) has been added effective 01/01/2025; check member coverage and prior authorization (PA) rules with Blue Cross Blue Shield - New Mexico for services on or after that date.

New CPT code: 86581 — effective 01/01/2025. Confirm PA requirements prior to claim submission.
If service date is on or after 01/01/2025, verify member-specific authorization via the payer portal or provider services.

Note

Documentation Required

Clinical Indication Documentation

Document clinical indication in the medical record to support reimbursable streptococcal serologic testing. For testing to be considered for reimbursement, the chart must include clear clinical documentation of one of the covered scenarios (see reimbursement restrictions). Examples of acceptable documentation: signs/symptoms and clinical suspicion of acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN); dates and results of prior bacterial culture or nucleic acid testing when the serology is a stated follow-up; and rationale for repeat or paired titers when monitoring a suspected or confirmed complication.

Ordering and Provider Limitations

Note

Ordering requirements — no explicit ordering-provider restriction

The policy excerpt does not impose specific ordering-provider restrictions; reimbursement is tied to the documented clinical indication and testing context rather than to a named ordering clinician type.

Ensure clinical documentation links the test to an allowed indication (ARF, PSGN, or follow-up after culture/nucleic acid test) when submitting claims.

Not Covered Services

Anti-streptolysin O immunoassay, hyaluronidase activity or anti-hyaluronidase immunoassay, and streptokinase activity or anti-streptokinase immunoassay are not covered except as described for suspected acute rheumatic fever (ARF), post-streptococcal glomerulonephritis (PSGN), or the specified follow-up testing after bacterial culture or nucleic acid testing. Providers should ensure documentation supports one of the reimbursable indications to avoid claim denial.

Frequency and Test Limits

Frequency limits

Frequency limitsNo specific frequency limits specified in the policy excerpt for streptococcal serology; frequency rules are blank in the frequency_limits section.

Repeat testing guidancePolicy ties reimbursement to clinical indications (e.g., suspected ARF or PSGN) and follow-up after culture or nucleic acid test; no separate repeat-interval is provided.

Follow-up test allowanceFollow-up serologic testing may be reimbursed when performed after a bacterial culture or a nucleic acid test for streptococcal infection (policy language updated to explicitly include nucleic acid testing).

Definitions and Test Names

Streptococcal serology definitions

ASO (Anti-streptolysin O)Anti-streptolysin O immunoassay — serologic test referenced for post-infectious complications and used to detect antibody response to streptolysin O.

Anti-hyaluronidase / hyaluronidase activity assayHyaluronidase activity or anti-hyaluronidase immunoassay — serologic test referenced for evaluation of post-streptococcal complications.

Streptokinase / anti-streptokinase assayStreptokinase activity or anti-streptokinase immunoassay — serologic test referenced for evaluation of post-streptococcal complications.

Related terminologyThese assays are collectively described as 'streptococcal serology' and are referenced in the policy as tests applicable to suspected acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis (PSGN).

Background and Evidence

Guidance and literature cited in the policy support targeted use of serologic testing in the evaluation of post-streptococcal complications rather than routine diagnosis of acute pharyngitis. The policy update history notes inclusion of evidence reviews and references (updated 03/01/2024 and again 10/30/2024) when expanding coverage to allow serologic titer testing, anti-streptolysin O, hyaluronidase, and streptokinase assays for suspected acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis (PSGN). The revisions also clarify follow-up testing reimbursement by explicitly including nucleic acid testing as an acceptable preceding test for a reimbursable follow-up serology. These changes reflect the literature-based approach described in the policy update history rather than routine use of serologic assays for uncomplicated group A streptococcal pharyngitis.