Diagnostic Testing of Common Sexually Transmitted Infections
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This reimbursement policy governs coverage and reimbursement criteria for diagnostic testing of common STIs (C. trachomatis, N. gonorrhoeae, T. pallidum, T. vaginalis and select others) for Blue Cross Blue Shield of New Mexico providers and members.
Added prenatal STI screening previously addressed on CPCPLAB014 Prenatal Testing (Non genetic), resulting in addition of #2.a, #5.e, #6.a, and #10.a.
For individuals currently or previously diagnosed with syphilis, treponemal Ig testing is not reimbursable.
For symptomatic individuals, testing for Mycoplasma genitalium using NAAT may be reimbursable; for asymptomatic individuals screening for M. genitalium using NAAT is not reimbursable.
Trichomonas vaginalis added to #24 as not reimbursable (direct probe/quantitative NAAT section); added specific CPT/other codes.
Qualitative NAAT phrasing added to several items for clarity (e.g., #4, #7, #12, #15).
Coverage and Reimbursement Criteria
Reimbursement stance and criteria
The policy specifies which diagnostic STI tests the Plan will reimburse and enumerates method- and indication-based exclusions. Reimbursable status depends on the test method, organism, and clinical circumstance.
- Procedure and proprietary codes listed in the policy identify tests commonly used for syphilis, chlamydia, gonorrhea, HSV, HPV, trichomonas, M. genitalium and multi-agent NAAT panels; see procedure code inventory for specific CPT/HCPCS/U-codes.
- Qualitative NAAT terminology was added for clarity and applies to coverage of many organism-specific NAATs (policy revisions noted).
- Policy moved prenatal STI screening into this document from CPCPLAB014; corresponding prenatal screening rules are now reimbursable as specified (e.g., chlamydia/gonorrhea NAAT and syphilis antibody at first prenatal visit for eligible ages).
- The policy explicitly adds and removes procedure codes over time; providers should reference the current code list when billing. Recent code additions and removals are recorded in policy history.
- Certain test methods are explicitly not reimbursable across organisms: PCR/NAAT/antigen testing for syphilis; culture/antibody/antigen testing for chlamydia or LGV; direct probe detection and/or quantitative NAAT for listed organisms; rapid enzyme immunoassay for Trichomonas; nucleic acid antimicrobial susceptibility/resistance testing for N. gonorrhoeae or M. genitalium.
Diagnosis of symptomatic infection for listed STIs
NAATs, antibody, culture, and other methods may be reimbursable for diagnosis of symptomatic infection when organism-specific criteria are met.
Diagnosis of symptomatic infection
- Syphilis: Antibody testing (treponemal and nontreponemal) reimbursable for persons presenting with signs/symptoms of syphilis.
- Chlamydia: Qualitative NAAT reimbursable for symptomatic individuals presenting with signs of chlamydial infection.
- Gonorrhea: Qualitative NAAT reimbursable for symptomatic individuals presenting with signs of gonococcal infection; culture for antimicrobial susceptibility reimbursable when treatment failure is suspected.
- Trichomonas: Qualitative NAAT reimbursable for symptomatic individuals; rapid enzyme immunoassay not reimbursable.
- Mycoplasma genitalium: NAAT testing may be reimbursable for symptomatic individuals; asymptomatic screening is not reimbursable.
- HSV: Qualitative NAAT for HSV-1 or HSV-2 may be reimbursable for individuals with active genital ulcers or mucocutaneous lesions; type-specific HSV-2 (gG2) antibody testing may be reimbursable in defined diagnostic circumstances.
Screening of asymptomatic individuals in defined high-risk groups
Screening of asymptomatic individuals is covered only for defined high-risk groups and per specified frequency intervals.
Screening criteria for asymptomatic high-risk groups
- Syphilis antibody screening reimbursable once per year for asymptomatic persons in a high-risk category.once per year
- Chlamydia qualitative NAAT reimbursable once per year for asymptomatic persons in a high-risk category; limited reimbursable screening for asymptomatic individuals not in high-risk groups (e.g., prenatal first visit for pregnant ≤24, newborn screening, sexual assault follow-up, sexually active <18 annually).once per year (high-risk)
- Gonorrhea qualitative NAAT reimbursable once per year for asymptomatic persons in a high-risk category; similar limited exceptions for asymptomatic not high-risk (prenatal, newborn, assault follow-up, sexually active <18 annually).once per year (high-risk)
- Trichomonas qualitative NAAT: annual screening reimbursable for asymptomatic individuals in high-risk groups and for persons with HIV infection.once per year
- Mycoplasma genitalium screening for asymptomatic individuals using NAAT is NOT reimbursable.
- PrEP-related screening: Qualitative NAAT for gonorrhea/chlamydia and syphilis blood testing reimbursable every 3 months for MSM and every 6 months for sexually active individuals while initiating or receiving PrEP.every 3 months (MSM) / every 6 months (sexually active)
Diagnostic testing for suspected or surveillance of sexually transmitted infections
Diagnostic testing and surveillance for suspected STIs are reimbursable when they align with organism- and method-specific rules described elsewhere in this policy.
Examples of diagnostic testing and surveillance indications
- Syphilis: Treponemal and nontreponemal serology for diagnosis, staging, and test-of-cure as indicated (see timing rules and exclusions).
- Chlamydia: Qualitative NAATs for diagnosis, suspected LGV, and test-of-cure per timing rules; culture/antigen/antibody methods not reimbursable.
- Gonorrhea: Qualitative NAATs for diagnosis and test-of-cure per timing rules; culture for antimicrobial susceptibility reimbursable for suspected treatment failure.
- Trichomonas: Qualitative NAAT for diagnosis and follow-up testing (minimum 3 months post-diagnosis); rapid enzyme immunoassay not reimbursable.
- HPV: HR-HPV testing reimbursable for cancer diagnosis/assessment (IHC p16 or NAAT for HR-HPV); HPV testing for routine asymptomatic STI panels is not reimbursable.
- HSV: NAAT for active lesions; type-specific serology for select diagnostic scenarios; non-specific antibody or antigen testing not reimbursable.
- Mycoplasma genitalium: NAAT reimbursable for symptomatic diagnosis; NAAT for antimicrobial resistance (macrolide) is not reimbursable.
Covered Indications and Organism-Specific Rules
Mycoplasma genitalium NAAT testing
Mycoplasma genitalium NAAT testing is limited to symptomatic diagnostic use; screening of asymptomatic persons is excluded.
M. genitalium NAAT testing
- NAAT testing for Mycoplasma genitalium may be reimbursable for symptomatic individuals when clinical signs/symptoms consistent with M. genitalium infection are present.
- Screening or NAAT testing for M. genitalium in asymptomatic individuals is NOT reimbursable.
- Nucleic acid testing to determine macrolide resistance in M. genitalium is NOT reimbursable.
PrEP-related STI screening
When providing or ordering PrEP-related STI screening, follow the frequency and test-type guidance below.
- Qualitative NAAT screening for gonorrhea and chlamydia reimbursable: once every 3 months for MSM while initiating or receiving PrEP.every 3 months (MSM)
- Qualitative NAAT screening for gonorrhea and chlamydia reimbursable: once every 6 months for sexually active individuals while initiating or receiving PrEP.every 6 months (sexually active)
- Syphilis blood testing reimbursable for PrEP users: once every 3 months for MSM and once every 6 months for sexually active individuals.every 3 months (MSM) / every 6 months (sexually active)
- Prior to initiating PrEP, triple hepatitis B panel (HBsAg, anti-HBs, total anti-HBc) may be reimbursable per referenced policy; see Hepatitis testing policy for details.
Procedure Codes and Coding References
| No codes listed |
| 86592 | SYPHILIS TEST NON-TREP QUAL. |
| 86593 | SYPHILIS TEST NON-TREP QUANT. |
| 86631 | CHLAMYDIA ANTIBODY. |
| 86632 | CHLAMYDIA IGM ANTIBODY. |
| 86694 | HERPES SIMPLEX NES ANTBDY. |
| 86695 | HERPES SIMPLEX TYPE 1 TEST. |
| 86696 | HERPES SIMPLEX TYPE 2 TEST. |
| 86780 | TREPONEMA PALLIDUM. |
| 87491 | CHLMYD TRACH DNA AMP PROBE. |
| 87492 | CHLMYD TRACH DNA QUANT. |
| No codes listed |
| 87140 | CULTURE TYPE IMMUNOFLUORESC. |
| 87270 | CHLAMYDIA TRACHOMATIS AG IF. |
| 87285 | TREPONEMA PALLIDUM AG IF. |
| 87320 | CHLMYD TRACH AG IA. |
| 87660 | TRICHOMONAS VAGIN DIR PROBE. |
| 87810 | CHLMYD TRACH ASSAY W/OPTIC. |
| 87494 | CHLMY TRCH&NEISRA GONOR MULT. |
| 87626 | HPV SEP HI-RSK TYP&POOL RSLT |
| 87563 | M. GENITALIUM AMP PROBE. |
| 0402U | ONC URTHL MRNA XPRSN 6 SNP. |
| No codes listed |
Screening Frequency and Follow-up Limits
Tests and Methods Not Reimbursable
This policy identifies several test methods that are not reimbursable. Specifically, PCR, NAAT, and antigen testing for syphilis are excluded from reimbursement (see item 4). Additionally, culture, antibody, and antigen testing for Chlamydia trachomatis or lymphogranuloma venereum (LGV) are not reimbursable (see items 5 and 7). For Trichomonas vaginalis, rapid enzyme immunoassay (rapid EIA) is explicitly listed as not reimbursable (see item 12). The policy also excludes direct probe detection and/or quantitative NAAT methods for a list of organisms including C. trachomatis, N. gonorrhoeae, HSV-1, HSV-2, T. pallidum, and T. vaginalis (see item 24).
Within the procedure-code listings portion of the policy, there are no additional explicit test-method exclusions beyond the not-reimbursable methods described elsewhere; this section primarily catalogs CPT/HCPCS and proprietary codes for STI-related assays and does not itself list separate exclusions (see Procedure Codes listings).
The policy was revised to add explicit exclusions related to syphilis testing: for individuals with a current or past syphilis infection, treponemal Ig testing is not reimbursable, and separately, PCR, NAAT, and antigen testing for syphilis are not reimbursable (see Policy History and item 4). These changes are recorded in the policy history and are operative in the reimbursement rules.
Provider Documentation, Billing, and Ordering Requirements
Documentation, coding and claims review
Providers must submit accurate documentation of services performed and code claims using valid code combinations from HIPAA-approved code sets and standard coding guidance. Claims are subject to code edit protocols and may require additional documentation; the provider is urged to submit any requested supporting documentation upon claim review.
Procedure code selection for STI tests (examples)
Use the procedure codes listed in the policy when billing STI diagnostics; examples include codes for syphilis, chlamydia, herpes, HPV, gonorrhea, trichomonas, Mycoplasma genitalium, and multi-organism NAAT panels.
PrEP pre-initiation HBV testing and PrEP STI screening intervals
Before initiating a PrEP regimen, triple-panel hepatitis B testing (HBsAg, anti-HBs, total anti-HBc) may be reimbursable; ongoing PrEP-related STI screening intervals are specified for qualitative NAATs and syphilis blood tests.
- Pre-initiation hepatitis B panel: HBsAg, anti-HBs, total anti-HBc (may be reimbursable).
- Qualitative NAAT screening for gonorrhea and chlamydia: once every 3 months for MSM; once every 6 months for sexually active individuals.
- Blood testing to screen for syphilis: once every 3 months for MSM; once every 6 months for sexually active individuals.
Ordering and documentation requirements for test orders
When ordering and billing STI tests, submit appropriate documentation and valid code combinations; ordering-provider restrictions are not specified in this excerpt but the policy notes that provider documentation and valid coding are required.
- Ensure claims use valid HIPAA-approved code sets and adhere to industry coding guidelines (CPT, HCPCS, ICD-10).
- Be prepared to provide additional documentation upon request to support medical necessity and correct coding.
No explicit ordering-provider restrictions in this excerpt
This policy excerpt does not specify limitations on which provider types may order tests; clinical guidance references (CDC, USPSTF, FDA and others) are cited for context in the policy.
- No ordering-provider restrictions are specified in the provided policy text.
- Clinical guidance sources are cited for recommended screening intervals and indications.
Screening interval guidance and note on prenatal screening
Follow recommended screening intervals referenced by the policy: qualitative NAATs and syphilis blood testing frequency guidance is included for MSM and sexually active individuals, and prenatal screening was moved into this policy.
- Qualitative NAAT for gonorrhea and chlamydia; syphilis blood testing: every 3 months for MSM and every 6 months for sexually active individuals.
- Prenatal STI screening items were transferred into this policy (policy history note).
Definitions and Testing Terminology
Ordering and Documentation Requirements
Ordering requirements — document clinical rationale and use valid codes (restrictions may exist elsewhere)
Provide appropriate documentation to support orders and ensure valid code combinations; this policy notes ordering-provider restrictions may apply (e.g., primary care versus specialist) in other sections, but specifics are not present in this excerpt.
- Include clinical rationale and supporting documentation with orders as requested during claim review.
- If plan or product documents impose ordering-provider restrictions, follow those rules when ordering and billing.
Ordering requirements — clinical guidance cited; no provider-type limits shown here
No ordering-provider restrictions are specified in this excerpt; the policy cites CDC, USPSTF and FDA guidance for clinical context and recommended screening intervals.
- Refer to cited clinical guidance (CDC, USPSTF, FDA) for screening recommendations referenced by the policy.
- Confirm any provider-type ordering limits in applicable Plan or contract documents.
Ordering requirements — recommended intervals for MSM and sexually active individuals; prenatal screening moved here
The policy explicitly references screening intervals for MSM and sexually active individuals (quarterly for MSM, semiannually for sexually active individuals) and indicates prenatal screening has been incorporated into this policy from the prior prenatal testing policy.
- Screening intervals: Qualitative NAAT for gonorrhea/chlamydia and syphilis blood testing — every 3 months for MSM; every 6 months for sexually active individuals.
- Prenatal screening provisions were moved into this policy (see policy history).
Policy Changes and Revision History
Policy approved; document updated with literature review and changes including moving prenatal STI screening into this policy, adding treponemal Ig testing exclusion for current/past syphilis, and multiple test-method clarifications and code additions/removals.
Added code 87494 (recorded in policy history as an addition on 04/24/2026).
Added the term 'qualitative' to NAAT references in several items and clarified NAAT mentions and reimbursement situations for Trichomonas and other items during a literature review update.
Added code 87626 and revised PrEP-related screening and pre-transplant testing statements; multiple code removals and reference updates recorded.
Clarified reimbursement for Mycoplasma genitalium NAAT (reimbursable when symptomatic; not reimbursable for asymptomatic screening), added Trichomonas vaginalis and M. genitalium to certain sections, and added multiple U-codes while removing others.
Original policy created (new policy) establishing diagnostic testing reimbursement rules for common STIs.
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