ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB045

Pathogen Panel Testing

Defines outpatient laboratory reimbursement criteria for multiplex and antigen pathogen panel testing and lists procedure codes and examples; applies to providers submitting claims to Blue Cross Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPathogen Panel Testing

Policy CodePolicy CPCPLAB045

Change TypeMaterial updates to coverage rules and code list

Effective DateJul 25, 2025

Next Review Date

Key ActionReimburse antigen or multiplex PCR respiratory panels of up to 5 pathogens only for symptomatic outpatients; documentation may be requested.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information revised to permit panel testing of up to 5 respiratory pathogens for individuals displaying signs and symptoms of a respiratory tract infection.

Several CPT/PLA codes were added and others removed (examples: added 87428, 0556U, 0563U, 0564U; added 0590U, 0593U effective 10/1/2025; removed 0240U, 0241U, 0370U, 0373U, 0374U).

Policy explicitly states molecular-based panel testing for general screening of microorganisms (examples provided) is not reimbursable.

up to 5reimbursable panel size

6+not reimbursable panel size

0CSF multiplex PCR reimbursed

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up to 5allowed pathogens (symptomatic)

Coverage Criteria for Outpatient Pathogen Panel Testing

Outpatient pathogen panel coverage rules

Outpatient reimbursement criteria and exclusions

Reimbursable: antigen panel testing or multiplex PCR-based respiratory panels of up to 5 respiratory pathogens for individuals displaying signs and symptoms of a respiratory tract infection (see Note 1).

Not reimbursable: antigen panel testing or multiplex PCR-based respiratory panels of 6 or more respiratory pathogens.

Not reimbursable: multiplex PCR-based panel testing of pathogens in cerebral spinal fluid (CSF).

Not reimbursable: molecular detection-based panel testing of pathogens in the blood.

Not reimbursable: molecular detection-based panel testing of urine pathogens for diagnosis of urinary tract infections (example: GENETWORx Molecular PCR UTI Test).

Not reimbursable: molecular-based panel testing to screen for or diagnose wound infections (example: GENETWORx PCR Wound Testing).

Not reimbursable: molecular-based panel testing for general screening of microorganisms (example: MicroGenDX qPCR+NGS).

Signs and symptoms that qualify for respiratory testing include fever, chills, fatigue, cough, rhinorrhea, new ageusia or anosmia, headaches, myalgia, diarrhea, weakness, and additional pediatric/infant signs as detailed in Note 1.

Coverage with criteria and exclusions

Coverage applies with clinical criteria and excludes general screening panels.

Panel testing of up to 5 respiratory pathogens (antigen panel testing or multiplex PCR-based panel testing) may be reimbursed for individuals displaying signs and symptoms of a respiratory tract infection (see Note 1).

Molecular-based panel testing for general screening of microorganisms is not reimbursable; examples include molecular-based vaginal swab panels (SmartJane), molecular-based urine panels (UroSwab), GENETWORx Molecular PCR UTI Test, GENETWORx PCR Wound Testing, and MicroGenDX qPCR+NGS.

Multiple CPT/PLA codes have been added and removed across updates; providers must reference the reimbursement section and update history for current valid codes and effective dates.

Procedure Codes, Limits, and Key Coding Values

Referenced procedure codesmixed

87154
87428
87483
87631
87632
87633
87636
87637
0068U
0086U

1–10 of 34

1/4

recently added and removed PLA/CPT codes (examples)CPT

87428
0556U
0563U
0564U
0590U
0593U
0240U
0241U
0370U
0373U

1–10 of 11

1/2

inv-05: Maximum reimbursable respiratory targets

Maximum reimbursable respiratory targetsPanel testing of up to 5 respiratory pathogens may be reimbursable.

Non-reimbursable larger panelsAntigen or multiplex PCR panels of 6 or more respiratory pathogens are not reimbursable.

Test types covered at this thresholdApplies to antigen panel testing or multiplex PCR-based panel testing when symptomatic.

inv-06: maximum pathogens on a reimbursable respiratory panel

Maximum pathogens allowedUp to 5 pathogens on a reimbursable respiratory panel.

Panels exceeding limitPanels of 6 or more respiratory pathogens are explicitly not reimbursable.

Provider Billing, Documentation, and Prior Authorization Guidance

Documentation Required

Documentation and claim review

Providers must submit accurate documentation of services performed and code claims using valid, industry-standard code sets. Claims are subject to code edit protocols and plan review; upon request, providers should submit any additional documentation to support the claim.

Submit claims using valid HIPAA-approved code combinations and industry standard coding guidelines.
Be prepared to provide additional documentation upon request; claims are subject to claim review, provider contract terms, medical policies, and coding edits.

Billing Rule

Outpatient-only restriction

This policy applies only to testing performed in the outpatient setting; the criteria do not apply to inpatient or other non‑outpatient settings.

Definitions and Scope Notes

inv-10: respiratory tract infection symptoms

Core qualifying symptomsFever, cough, rhinorrhea, new ageusia or anosmia, chills, fatigue, headaches, myalgia, diarrhea, weakness; these qualify individuals for respiratory panel testing.

Associated ENT/GI symptomsAnorexia, pharyngitis, vomiting may be present with respiratory infection.

Pediatric/infant signsFor <18 years: irritability, decreased activity, nausea, rash, stomach pain, ear tugging/otalgia, wheezing, tachypnea, retractions, grunting, crackles, cyanosis, apnea; infants may show poor feeding, lethargy, fussiness.

inv-11: outpatient restriction

Setting restrictionThis policy and its outpatient reimbursement criteria apply only to testing performed in the outpatient setting.

Non-applicability

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPathogen Panel Testing

Policy CodePolicy CPCPLAB045

Change TypeMaterial updates to coverage rules and code list

Effective DateJul 25, 2025

Next Review Date

Key ActionReimburse antigen or multiplex PCR respiratory panels of up to 5 pathogens only for symptomatic outpatients; documentation may be requested.

SourceLink

On This Page

Applicable testsLimit applies to both antigen panel testing and multiplex PCR-based panel testing.

Tests performed outside the outpatient setting are excluded from these criteria.

Billing Rule

Prior authorization / billing guidance — respiratory panels

Panel testing of up to 5 respiratory pathogens (antigen or multiplex PCR) may be reimbursed for individuals displaying signs and symptoms of a respiratory tract infection; refer to the reimbursement section and policy update history for added and removed CPT/PLA codes and effective dates.

Reimbursable: antigen or multiplex PCR respiratory panels of up to 5 pathogens for symptomatic individuals (see Note 1).
Review Policy Update History for examples of added codes (e.g., 87428, 0556U, 0563U, 0564U, 0590U, 0593U) and removed codes (e.g., 0240U, 0241U, 0370U, 0373U, 0374U) with effective dates.

Criteria do not apply to testing performed in inpatient or other non-outpatient settings.

Provider action implicationProviders must follow other plan documents or facility-specific rules for non-outpatient settings.

inv-12: Respiratory tract infection (Note 1)

Comprehensive symptom list (Note 1)Signs and symptoms include fever, chills, fatigue, cough, rhinorrhea, anorexia, pharyngitis, vomiting, new ageusia or anosmia, headaches, myalgia, diarrhea, and weakness.

Additional pediatric signsIn individuals <18 years: irritability, decreased activity, nausea, rash, stomach pain, ear tugging/otalgia, vomiting after coughing, tachypnea, chest retractions/nasal flaring, grunting, wheezing, crackles, dehydration, cyanosis, apnea episodes, drooling, or refusal to eat.

Infant presentationsInfants may present with non-specific signs such as poor feeding, lethargy, and fussiness rather than clear localizing symptoms.