CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO68

Onychomycosis Testing

Defines BCBSNM laboratory reimbursement stance for tests used to diagnose or confirm onychomycosis and indicates which test methods are reimbursable or not for members covered under BCBSNM plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOnychomycosis Testing

Policy CodePolicy CPCPLABO68

Change TypeReimbursement clarification (revision)

Effective DateJun 15, 2023

Next Review Date

Key ActionSubmit accurate documentation and code claims using valid HIPAA-approved code sets; BCBSNM may request additional documentation.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity.

New policy created and implemented effective 6/15/2023.

1reimbursable test type listed

3non-reimbursable test categories

14procedure codes listed

6/15/2023plan effective

Onychomycosis Testing Coverage Criteria

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.

Direct microscopic examination with potassium hydroxide (KOH), fungal culture of desquamated subungual material, or fungal stain of a nail clipping(s) may be reimbursable for individuals with onychomycosis.

Nucleic acid tests (e.g., PCR, PCR-RFLP, next-generation sequencing) to screen for, diagnose, or confirm onychomycosis are not reimbursable.

Attenuated total-reflectance Fourier transform infrared (ATR-FTIR) spectroscopy to screen for, diagnose, or confirm onychomycosis is not reimbursable.

Testing for the presence of fungal-derived sterols (e.g., ergosterol) is not reimbursable.

Coverage and applicability may vary by product; providers should review member plan documents for eligible coverage and submit documentation and codes per standard coding guidelines.

Procedure Codes and Reimbursement Guidance

Procedure codes referencedmixed

82542	Fungal antigen or organism detection (example listed in policy)
87101	Culture, fungal; pathogenic or presumptive species identification
87149	Fungal exam; other
87150	Fungal exam; identification by biochemical/other methods
87153	Fungal smear or culture, other codes listed
87205	Fungal stain; fluorescent
87206	Fungal stain; other
87220	Culture, fungal or mycobacterial
87480	Infectious agent detection by nucleic acid (note: nucleic acid tests are listed as not reimbursable for onychomycosis)
87481	Infectious agent detection by nucleic acid

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Nucleic acid testing reimbursement

Policy positionNot reimbursable for screening, diagnosis, or confirmation of onychomycosis using nucleic acid tests (e.g., PCR, PCR-RFLP, NGS)

Applicable specimens/usesApplies when testing to screen for, diagnose, or confirm onychomycosis

Related non-reimbursable methodsAlso listed as not reimbursable alongside ATR-FTIR spectroscopy and testing for fungal-derived sterols (e.g., ergosterol)

Documentation and Coding Requirements

Documentation Required

Documentation and coding requirements — submit accurate, HIPAA‑approved codes and supporting documentation

Providers must submit accurate documentation of services performed and submit claims using valid code combinations from HIPAA‑approved code sets. Claims should be coded according to industry standard coding guidelines (for example, UB editor, AMA CPT, HCPCS, ICD‑10, NDC, DRG, CMS NCCI policy/manual and CCI table edits). BCBSNM may request additional documentation and applies code edit protocols and claim review (including plan documents, provider contracts, medical policies, and coding software logic) when adjudicating claims.

Use valid HIPAA‑approved code sets and appropriate code combinations when submitting claims.
Code according to industry standard guidelines (UB, AMA CPT, HCPCS, ICD‑10, NDC, DRG, CMS NCCI/CCI edits).
Be prepared to provide additional documentation upon BCBSNM request; claims are subject to code edit protocols and claim review including plan and contract terms.

Definitions of Test Methods

Nucleic acid testing (examples)

DefinitionNucleic acid testing of fungal organisms refers to molecular methods such as PCR, PCR-RFLP, and next-generation sequencing (NGS)

Examples of organisms testedCandida spp., Aspergillus spp., Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum, Neoscytalidium dimidiatum, Onychocola canadensis, Scopulariopsis spp., Alternaria spp., Acremonium spp., Fusarium spp.

Clinical noteThese nucleic acid tests are specifically noted in the policy as not reimbursable when used to screen for, diagnose, or confirm onychomycosis

ATR-FTIR spectroscopy (ATR-FTIR)

TermAttenuated total-reflectance Fourier transform infrared (ATR-FTIR) spectroscopy

DefinitionAn infrared spectroscopic technique (ATR-FTIR) used to characterize sample molecular composition; listed in this policy as a diagnostic method for onychomycosis

Policy positionATR-FTIR spectroscopy is not reimbursable to screen for, diagnose, or confirm onychomycosis