Helicobacter pylori Testing
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Reimbursement criteria for diagnostic and post-treatment testing for H. pylori for Blue Cross Blue Shield - New Mexico members; applies to providers submitting claims for laboratory/pathology services under this payer.
Urea breath testing or stool antigen testing to document eradication performed at least four weeks post-treatment is included as reimbursable.
Susceptibility testing (culture or nucleic acid based) is reimbursable for refractory H. pylori infection.
Clarified and expanded the adult indications list for noninvasive testing (urea breath or stool antigen) including dyspepsia, PUD, MALT lymphoma, gastric intestinal metaplasia, NSAID/aspirin use, unexplained iron deficiency anemia, ITP, family history of gastric cancer, and first-generation immigrants from high prevalence areas.
Explicit prohibitions: serology for H. pylori is not reimbursable for any age; concurrent multiple-test diagnostic approaches are not reimbursable; testing after recent antibiotics, PPIs, or bismuth is not reimbursable.
Added CPT code 87513 to the procedure code list.
Coverage and Medical Necessity Criteria
Coverage criteria — Reimbursable H. pylori testing by age, test type, and clinical scenario
Covered when the conditions below are met:
Indications Where Testing Is Reimbursable
Procedure Codes and Frequency Notes
| 83009 | H PYLORI (C-13) BLOOD |
| 83013 | H PYLORI (C-13) BREATH |
| 83014 | H PYLORI DRUG ADMIN |
| 86318 | IA INFECTIOUS AGENT ANTIBODY |
| 86677 | HELICOBACTER PYLORI ANTIBODY |
| 87070 | CULTURE OTHR SPECIMN AEROBIC |
| 87077 | CULTURE AEROBIC IDENTIFY |
| 87081 | CULTURE SCREEN ONLY |
| 87149 | DNA/RNA DIRECT PROBE |
| 87150 | DNA/RNA AMPLIFIED PROBE |
Ordering, Documentation, and Claim Submission
Documentation, coding, and potential request for additional records
Providers are responsible for submitting accurate documentation of services performed and should code claims using valid, industry-standard code sets; claims are subject to code edit protocols and review. Upon request, the provider may be asked to submit additional documentation to support the claim.
- Submit claims using valid code combinations from HIPAA-approved code sets and code appropriately per industry coding guidelines.
- Claims are subject to code edit protocols and claim review; provide additional documentation upon request.
Ordering Requirements
Document clinical indication and link orders to endoscopy/biopsy encounters
Document the clinical indication for H. pylori testing in the medical record; for endoscopic or biopsy-based testing, ordering typically occurs in the setting of endoscopy or for patients with alarm symptoms and should be reflected in the order and documentation.
- Record the specific clinical scenario (e.g., dyspepsia, active PUD, alarm symptoms) that supports testing.
- For endoscopic evaluations, ensure the biopsy-based histology request and accompanying rapid urease or culture/susceptibility testing order are documented as part of the endoscopy encounter.
Services and Situations Not Reimbursable
Serologic (antibody) testing for Helicobacter pylori is explicitly excluded from reimbursement for individuals of all ages. Providers should not submit claims for H. pylori serology as this test is not reimbursable under this policy.
Diagnostic testing to detect H. pylori infection is not reimbursable for asymptomatic individuals of any age. Claims for urea breath test, stool antigen, or biopsy-based diagnostic testing submitted for asymptomatic patients will be denied.
Testing to diagnose H. pylori infection performed within the period of recent antibiotic, proton pump inhibitor (PPI), or bismuth use is not reimbursable. Providers must ensure appropriate medication-free intervals before ordering diagnostic urea breath, stool antigen, or biopsy-based tests.
Concurrent use of multiple diagnostic modalities—such as performing a urea breath test, stool antigen test, and biopsy-based testing together for initial diagnosis—is not reimbursable. Only a single appropriate diagnostic approach should be used when establishing an initial H. pylori diagnosis.
Nucleic acid testing for H. pylori is not reimbursable in general. An exception exists for individuals with a refractory H. pylori infection: in that specific context, nucleic acid–based methods used for susceptibility testing (in addition to culture-based susceptibility testing) may be reimbursable.
In pediatric patients (<18 years), endoscopic biopsy-based testing (histology, rapid urease testing, or culture) to diagnose H. pylori is not reimbursable when performed for functional abdominal pain, as part of the initial evaluation of iron deficiency anemia, or when investigating short stature. Such biopsy-based diagnostic procedures in these listed pediatric-limited indications will not be reimbursed.
Testing Frequency and Timing
Definitions and Clinical Terms
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