CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB057

Coronavirus Testing in the Outpatient Setting

This Clinical Payment and Coding Policy governs reimbursement criteria for outpatient SARS-CoV-2 (COVID-19) testing and related lab services for Blue Cross Blue Shield New Mexico members; providers should review specific plan documents for product-specific applicability.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB057

Change TypeCode additions/removalsliterature review updates

Effective DateMarch 15, 2024

Next Review DateN/A

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request; code claims per standard coding guidelines.

SourceLink

POLICY UPDATE CHANGES

Added code 0408U.

Removed codes G2023, G2024, U0003, U0004, U0005.

Document updated with literature review; references revised with additions and removals.

1.0policy version

Mar 15, 2024plan effective date

1code added (0408U)

5codes removed

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not reimbursable — antigen panels ≥6

Coverage and Clinical Criteria

Procedure Codes and Coding Guidance

Example SARS-CoV-2 testing and serology codesmixed

86318
86328
86408
86409
86413
86769
86790
87426
87428
87631

1–10 of 27

1/3

EUA assay referencesmixed

References include EUA summaries for specific assays (e.g., Poplar TMA pooling assay, QIAstat-Dx Respiratory SARS-CoV2 Panel, Sofia 2 SARS Antigen FIA)

Updated codesmixed

0408U	Code added per policy update
G2023	Code removed per policy update
G2024	Code removed per policy update
U0003	Code removed per policy update
U0004	Code removed per policy update
U0005	Code removed per policy update

Reference count — inv-07: Multiple peer-reviewed and regulatory documents

Number of referencesMultiple peer-reviewed and regulatory documents cited (20+ items across chunks 18-37).

Types of sourcesPeer-reviewed studies, public health guidance, and regulatory EUA summaries (FDA, NIH, CDC, ECDC, IDSA).

Representative citationsExamples include Mak et al. 2020 (rapid antigen evaluation) and NIH Clinical Spectrum guidance.

Document chunk rangeReferences appear across chunks 18-37 (detailed lists in chunks 29, 32, 36).

Reimbursement change — inv-08

Reimbursement status as of 03/01/2024Reimbursement information unchanged (03/01/2024).

Code changes notedPolicy update history records code additions/removals but indicates reimbursement unchanged on 03/01/2024.

Policy update summaryDocument updated with literature review; references revised with additions and removals.

Provider Responsibilities and Operational Guidance

Documentation Required

Documentation and claims review — Providers are responsible for submission of accurate documentation of services performed and may be asked to submit additional documentation upon request.

Providers are responsible for submission of accurate documentation of services performed and may be asked to submit additional documentation upon request. Claims must be submitted using valid HIPAA-approved code sets and appropriately coded per industry standards (e.g., UB, AMA CPT®, HCPCS, ICD-10, NDC, DRG). Claims are subject to code edit protocols and claim review, including but not limited to benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.

Submit additional documentation upon request
Use valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.)
Claims subject to code edit protocols and review

Note

FDA EUA and transition guidance references — References to FDA EUA summaries and transition plans (e.g., Emergency Use Authorization, Transition Plan for Medical Devices issued EUAs).

Providers should be aware of and follow FDA Emergency Use Authorization (EUA) guidance and transition plans when billing for tests or devices that were authorized under an EUA. This includes referencing FDA EUA summaries for specific assays and the FDA Transition Plan for Medical Devices Issued EUAs related to COVID-19 when applicable. Coverage and coding determinations may depend on the device/test EUA status and any subsequent FDA transition or enforcement policies.

Definitions and Reference Terms

Plan documents / governance — inv-12

Plan documents definedIncludes Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Governance precedenceWhen conflict exists, the applicable plan document governs over this CPCP; provider contracts govern where applicable.

BCBSNM discretionBCBSNM may use reasonable discretion interpreting and applying this policy and has final discretionary authority as provided under plan documents.

Signs and symptoms of COVID-19 (NOTE 2) — inv-13

Symptom list (NOTE 2)Fever, cough, fatigue, shortness of breath or difficulty breathing, congestion or runny nose, chills, muscle pain, sore throat, new loss of taste or smell, nausea, vomiting, diarrhea, conjunctivitis, rash, discoloration of fingers or toes.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB057

Change TypeCode additions/removalsliterature review updates

Effective DateMarch 15, 2024

Next Review DateN/A

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request; code claims per standard coding guidelines.

SourceLink

On This Page

Refer to FDA EUA summaries for specific tests (e.g., Illumina COVIDSeq Test)
See FDA resources: In Vitro Diagnostics EUAs; Policy for COVID-19 Tests During the PHE; Transition Plan for Medical Devices Issued EUAs
Billing and coverage may change when an EUA ends and devices transition to full approval or other enforcement policies

Note

Policy Update History — Policy update history lists code additions and removals; reimbursement information unchanged on 03/01/2024.

Policy update history documents changes to codes and references; providers should confirm current coding and reimbursement guidance prior to billing. Reimbursement information was unchanged on 03/01/2024 per the policy history.

03/01/2024: Added code 0408U; reimbursement information unchanged
Removed codes: G2023, G2024, U0003, U0004, U0005 (dates as noted in history)
11/01/2023 and 11/01/2022: Literature review updates and policy creation

NOTE 2 lists these signs and symptoms as associated with possible COVID-19 infection for determining testing reimbursement criteria.

Source guidance citedCDC and WHO sources referenced in NOTE 2 (CDC, 2022f; WHO, 2023a).

EUA — inv-14

DefinitionEmergency Use Authorization (EUA).

Related referencesFDA EUA summaries and policy/transition documents cited (e.g., FDA In Vitro Diagnostics EUAs, Transition Plan for Medical Devices issued EUAs).

Use in policyEUA status is referenced for antibody testing and assay EUA summaries within the policy references.

Clinical Spectrum — inv-15

TermClinical Spectrum of SARS-CoV-2 Infection.

ReferenceNIH Clinical Spectrum guidance cited (NIH, 2022a).

RelevanceUsed as supporting material for clinical presentation and testing guidance in the policy.

References — inv-16

SectionReferences (bibliography) listing peer-reviewed articles, guidance, and regulatory documents used to support the policy.

Representative entriesIncludes Seo et al. 2020, Mak et al. 2020, NIH clinical guidance, and multiple FDA EUA documents.

ScopeReferences span public health agencies, journals, and regulatory EUA summaries across chunks 18-37 and 36-44.

Policy Update History — inv-17

Record of updatesPolicy Update History records literature review updates and code changes (added 0408U; removed G2023, G2024, U0003, U0004, U0005).

Dates notedEntries include 11/1/2022 (new policy), 11/01/2023 (literature review, revisions), and 03/01/2024 (added 0408U; reimbursement unchanged).

Reimbursement impactPolicy explicitly states reimbursement information unchanged in the 03/01/2024 entry.