DraftBlue Cross Blue Shield - New MexicoPolicy CPCPLABOS7

Coronavirus Testing in the Outpatient Setting

This policy outlines lab management reimbursement criteria for SARS-CoV-2 (COVID-19) testing in the outpatient setting and the circumstances under which testing may be reimbursable for Blue Cross and Blue Shield of New Mexico members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLABOS7

Change TypeRevisions including code removals, modality updates, and redirection of items to CPCPLABO4S

Effective DateNovember 7,2025

Next Review Date

Key ActionSubmit accurate documentation with claims and provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Edited reimbursement information item #1 to remove duplicate wording 'including rapid molecular tests' and clarify applicability of listed situations for testing.

Removed reimbursement items #6 and #7 and Note 5 because they are addressed in CPCPLABO4S Pathogen Panel Testing.

Added rapid molecular tests as a testing option in reimbursement information item #1.

Added NAAT as an acceptable test option for MIS-A and MIS-C and updated frequency in item #5 to once every 48 hours; removed items #7, #8, and #9 relating to genotyping and other testing addressed elsewhere.

Removed listed CPT/HCPCS/Lab codes: 86790, 87631, 87632, 87633, 87797, 87799, 0115U, 0202U, 0223U, 0225U, C9803.

Added code 0408U.

Removed codes 62023, 62024, U0003.

1.0policy version

2025-11-07

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.

2025-07-25approval date

11example codes provided

multiplecodes removed

Reimbursable SARS-CoV-2 Testing Scenarios

Reimbursable and non-reimbursable scenarios

Situations where SARS‑CoV‑2 testing may be reimbursable:

ANY of the following

ALL of the following
- Individuals displaying signs and symptoms of possible COVID-19 infection (see Note 2).
ALL of the following
- Asymptomatic individuals with known exposure to COVID‑19, except when the individual has had a previous COVID‑19 infection within the last 90 days.
ALL of the following
- Individuals with signs or symptoms of severe acute respiratory syndrome (SARS) who have traveled to endemic areas or who have been exposed to persons with SARS; targeted nucleic acid testing (e.g., RT‑PCR) may be reimbursable.
- Individuals with signs or symptoms of Middle East respiratory syndrome (MERS) who have traveled to endemic areas or who have been exposed to persons with MERS; targeted nucleic acid testing (e.g., RT‑PCR) may be reimbursable.
ALL of the following
- To support diagnosis of multisystem inflammatory syndrome in children (MIS‑C), multisystem inflammatory syndrome in adults (MIS‑A), or post‑acute sequelae of SARS‑CoV‑2 infection (PASC), nucleic acid amplification testing and host antibody serology testing may be reimbursable.
ALL of the following
- For symptomatic individuals, antigen‑detecting diagnostic tests for SARS‑CoV‑2 (antigen rapid tests) may be reimbursable once every 48 hours.once every 48 hours

ALL of the following

Host antibody serology testing is not reimbursable for situations not described in this policy.
Neutralization antibody testing for SARS‑CoV‑2 is not reimbursable for any situation.
Testing for other endemic coronaviruses (229E, NL63, OC43, HKU1) is not reimbursable.
Antibody testing provided under an FDA Emergency Use Authorization (EUA) during a public health emergency is NOT addressed by this policy.

ALL of the following

Inclusion of a code in the procedure code list does not guarantee coverage; claims are subject to plan terms, coding guidelines, and claim review processes.

Reimbursement updates and pointers

Summary of reimbursement information changes and redirections:

ALL of the following

01/23/2025 updates: Added rapid molecular tests as a testing option in item #1; added NAAT as an acceptable test option for MIS‑A and MIS‑C in item #4; updated antigen testing frequency in item #5 to once every 48 hours; removed items redirected to CPCPLABO4S (e.g., certain panel/genotyping items).
03/01/2024 update: Added code 0408U to the code list.
03/15/2024 and 01/23/2025 code removals: Several CPT/HCPCS/Lab codes were removed across updates (examples listed in policy update history); these removals affect the policy code list but do not by themselves establish coverage.
11/07/2025 literature review: Edited reimbursement item #1 to remove duplicative wording and clarify applicability; removed items that are now managed under CPCPLABO4S Pathogen Panel Testing.

ALL of the following

Example Procedure and Lab Codes

Example SARS-CoV-2 testing codes (not exhaustive)mixed

86328
86408
86409
86413
86769
87426
87635
87798
87811
0224U

1–10 of 12

1/2

Code list completeness — Not an all-encompassing code list; inclusion does not guarantee coverage

Scope of code listThe procedure code list is not all‑encompassing; it is an example list and does not include every possible code for SARS‑CoV‑2 testing.

Coverage not guaranteed by inclusionInclusion of a code in this document does not guarantee it is a covered service or eligible for reimbursement.

Claims subject to plan rulesActual reimbursement depends on member plan terms, coding guidelines, and claims review processes.

testing_frequency_for_item_5 — once every 48 hours (operational testing frequency guidance)

Testing frequency for symptomatic antigen testsFor symptomatic individuals, antigen‑detecting diagnostic tests for SARS‑CoV‑2 may be reimbursable once every 48 hours.

Documentation, Claims, and Reimbursement Procedures

Documentation Required

Documentation and provider responsibilities

Providers are responsible for submission of accurate documentation of services performed and are urged to submit any additional documentation upon request. Claims should be coded using valid HIPAA-approved code sets and according to industry standard coding guidelines (CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI policy manual, CCI edits, etc.).

Submit claims using valid code combinations from HIPAA-approved code sets.
Code claims according to industry-standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI policy manual, CCI table edits).
Provide additional documentation upon request to support claims.

Billing Rule

Claims review and code edit protocols

Clinical Definitions and References

Signs and symptoms — Signs and symptoms associated with possible COVID-19 infection

Common signs and symptomsFever, cough, fatigue, shortness of breath or difficulty breathing, congestion or runny nose, chills, muscle or body aches, headache, sore throat; new loss of taste or smell.

Gastrointestinal and other symptomsNausea, vomiting, diarrhea, conjunctivitis (eye symptoms).

Use in reimbursement criteriaIndividuals displaying these signs and symptoms are listed in the policy as potentially reimbursable for SARS‑CoV‑2 testing (see Reimbursement Information).

MIS-C — Multisystem inflammatory syndrome in children (MIS-C) case definition includes hospitalization, fever >=38°C, elevated CRP and new onset ...

Age criterion and severityMIS‑C is defined in persons under 21 years with clinical severity requiring hospitalization.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLABOS7

Change TypeRevisions including code removals, modality updates, and redirection of items to CPCPLABO4S

Effective DateNovember 7,2025

Next Review Date

Key ActionSubmit accurate documentation with claims and provide additional documentation upon request.

SourceLink

On This Page

Certain reimbursement items have been removed or redirected to policy CPCPLABO4S Pathogen Panel Testing; providers should reference CPCPLABO4S for panel/pathogen testing reimbursement rules.
Claims remain subject to documentation, code edit protocols, and plan terms; providers are responsible for submission of accurate documentation and may be asked to supply additional records during claims review.

Context of frequency updatePolicy update on 01/23/2025 revised item #5 to specify the once every 48‑hour frequency.

Applicability noteFrequency applies to antigen‑detecting diagnostic tests as described in Reimbursement Information item #5; other modalities follow their own criteria.

Claims are subject to code edit protocols and claim review, including review of benefit coverage, provider contract language, medical policies, and coding software logic. Providers should expect adjudication consistent with these reviews.

Claims submissions are reviewed against plan benefit terms and provider contract provisions.
Claims are subject to clinical payment and coding policy checks and automated code-edit logic.

Billing Rule

Reimbursement edits and redirections

The policy update history redirects certain reimbursement items to CPCPLABO4S Pathogen Panel Testing and documents changes that affect acceptable test options (e.g., addition of rapid molecular tests and NAAT for MIS-A/MIS-C) and testing frequency (updated to once every 48 hours).

Removed reimbursement items (#6, #7 and related Note 5) and redirected them to CPCPLABO4S Pathogen Panel Testing.
Added rapid molecular tests as an acceptable testing option in Reimbursement Information item #1 (01/23/2025 update).
Added NAAT as an acceptable test option for MIS-A and MIS-C and updated item #5 frequency to once every 48 hours (01/23/2025 update).
Multiple CPT/HCPCS/Lab codes were removed (e.g., 86790, 87631, 87632, 87633, 87797, 87799, 0115U, 0202U, 0223U, 0225U, C9803) and code 0408U was added per update history.

Fever requirementSubjective or documented fever of at least 38°C is required.

Inflammation markerEvidence of systemic inflammation indicated by elevated C‑reactive protein (CRP).

Multisystem involvementNew onset manifestations in at least two categories (examples: cardiac, mucocutaneous, gastrointestinal, hematologic) such as coronary artery changes, rash, conjunctivitis, vomiting, abdominal pain, thrombocytopenia.

Hospitalization timing and additional criteriaClinical criteria include hospitalization for ≥24 hours or other specified temporal and clinical findings (see full CDC‑derived definition in policy notes).

MIS-A — Multisystem inflammatory syndrome in adults (MIS-A) is defined by CDC criteria (referenced)

Reference to CDC criteriaMIS‑A is defined according to CDC criteria for persons 21 years of age or older (see Note 4 in the policy).

Associated testing guidancePolicy indicates nucleic acid amplification testing and host antibody serology may be reimbursable to support diagnosis of MIS‑A.

Update noting NAAT acceptancePolicy update (01/23/2025) added NAAT as an acceptable test option for MIS‑A (and MIS‑C).

References (SARS-CoV-2 diagnostics and guidance) — Peer-reviewed studies and official guidance citations

Peer‑reviewed diagnostic studiesReferences include peer‑reviewed evaluations of RT‑LAMP, RT‑qPCR, RT‑LAMP‑CRISPR, saliva diagnostics, and whole‑genome sequencing for SARS‑CoV‑2 detection (see references 81–84, 86, 87, 88, 90–94).

Regulatory and guidance sourcesIncludes FDA EUA summaries and test documentation and WHO/CDC guidance documents on diagnostic testing and antigen test use (see chunks listing FDA and WHO citations).

Public health and sequencing guidanceReferences cite CDC and ECDC guidance on whole‑genome sequencing, surveillance strategies, and genomic monitoring (see chunks 18–23 references).