CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO53

Hemolytic Streptococcus Testing reimbursement

Reimbursement and coding criteria for laboratory testing related to hemolytic streptococcal infections for Blue Cross and Blue Shield of New Mexico members and providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHemolytic Streptococcus Testing reimbursement

Policy CodePolicy CPCPLABO53

Change TypeAdded CPT coderevised reimbursement criteria

Effective DateJanuary 15, 2025

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional records upon request; claims are subject to review.

SourceLink

POLICY UPDATE CHANGES

Added new CPT code 86581 effective 01/01/2025.

Updated reimbursement criteria to include nucleic acid testing as a follow-up test when prior culture or NAAT was performed.

Added reimbursable serologic and immunoassay testing for suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN).

2025-01-15Plan Effective Date

86581New CPT code

multipleRules listed

Reimbursement Criteria and Limitations

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHemolytic Streptococcus Testing reimbursement

Policy CodePolicy CPCPLABO53

Change TypeAdded CPT coderevised reimbursement criteria

Effective DateJanuary 15, 2025

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional records upon request; claims are subject to review.

SourceLink

On This Page

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ALL of the following

ONE of
- Modified Centor score of 3 or greater (see Centor criteria).
- Suspected bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea).
- Following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent.

ALL of the following

ONE of
- Individual fails to demonstrate clinical improvement.
- Individual has progressive symptoms or clinical deterioration after initiation of antibiotic therapy.
- Suspected prosthetic joint infection.

Skin and soft tissue bacterial culture for streptococcal infection is reimbursable when collected from an appropriate specimen (skin swab or pus).

ALL of the following

Serological titer testing.
Anti-streptolysin O (ASO) immunoassay.
Hyaluronidase activity or anti-hyaluronidase immunoassay.
Streptokinase activity or anti-streptokinase immunoassay.

Not reimbursable: In cases of suspected viral pharyngitis, bacterial throat culture for streptococci is not reimbursable.

ALL of the following

NOT reimbursable for
- As a follow-up test after a bacterial culture test or a nucleic acid test for streptococcal infection.
- As a screening method in an asymptomatic patient.
- For individuals with suspected viral pharyngitis.

Serological titer testing is not reimbursable except as described above for suspected ARF or PSGN.

Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter is not reimbursable.

ALL of the following

Panel tests that screen and identify multiple streptococcal strains using immunoassay or nucleic acid-based assays (e.g., Solana Strep Complete Assay, Lyra Direct Strep Assay).
MALDI-TOF identification of streptococcus.
Quantification of any strain of streptococcus using nucleic acid amplification methods, including PCR.
Nicotinamide-adenine dinucleotidase activity or anti-nicotinamide-adenine immunoassay.

Documentation, Claims, and Provider Requirements

Documentation Required

Documentation and claim review

Providers must submit complete and accurate clinical documentation to support test reimbursement. Claims are subject to review against benefit coverage, provider contract terms, medical and coding policies, and coding edit logic. Upon request, providers should supply additional clinical records, test results, or provider notes to substantiate medical necessity.

Providers must code services using HIPAA-approved code sets (CPT, HCPCS, ICD-10) and follow industry standard coding guidelines.
Claims are subject to code edit protocols and may be denied or adjusted if coding or documentation is insufficient.
When requested, submit supporting documentation (clinical notes, Centor scoring, RADT results, culture results) to expedite claim review.

Billing Rule

Clinical criteria for test reimbursement

Reimbursement for streptococcal testing is contingent on meeting documented clinical criteria. Providers should document the clinical findings and test sequence that justify ordering the specific test.

For throat bacterial culture testing: document a modified Centor score of >= 3 OR absence of viral features (e.g., cough, oral ulcers, rhinorrhea) OR suspicion of bacterial pharyngitis following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent.
For blood cultures: document clinical justification such as failure to improve, progressive symptoms or deterioration after antibiotics, or suspected prosthetic joint infection.
For skin/soft tissue infections: document source (skin swab or pus) and clinical suspicion of streptococcal involvement.
For suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN): document clinical concern and order appropriate serologic testing (e.g., titers, anti-streptolysin O) as indicated.
RADT is not reimbursable as a screening test in asymptomatic patients, as a follow-up to culture or nucleic acid testing, or for suspected viral pharyngitis. Exceptions: asymptomatic children under age three with mitigating circumstances (e.g., symptomatic household member).
Do not order simultaneous direct probe and amplification probe for the same organism in one encounter; this is not reimbursable.
Tests not reimbursable in all situations include panel assays that identify multiple streptococcal strains, MALDI-TOF identification of streptococcus, quantification of streptococcal strains by nucleic acid amplification (including PCR), and specified immunoassays (e.g., nicotinamide-adenine dinucleotide activity assays).

OpenPayer

Hemolytic Streptococcus Testing reimbursement

Reimbursement Criteria and Limitations

Procedure Codes and Coding Rules

Documentation, Claims, and Provider Requirements

Clinical Definitions and Scoring