CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP LAB053

β-Hemolytic Streptococcus Testing reimbursement and coding policy

Defines BCBSNM reimbursement criteria, coding guidance, and limits for testing related to β-hemolytic streptococcal infections (including RADT, cultures, serology, and molecular assays) for applicable members and providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policyβ-Hemolytic Streptococcus Testing reimbursement and coding policy

Policy CodePolicy CPCP LAB053

Change TypeClarified (administrative wording changes)

Effective DateSeptember 1, 2023

Next Review DateN/A

Key ActionSubmit accurate documentation and claims using HIPAA-approved code sets; claims may be reviewed and require additional documentation.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information revised for clarity only; no new information added.

New policy created on 11/1/2022.

2023-09-01policy effective date

1.0policy version

2023-07-05approval date

11/1/2022policy creation date

19+references

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.

Reimbursement and Coverage Criteria

Reimbursement Criteria for β-hemolytic streptococcus testing

Reimbursement Information: Covered or reimbursable testing and denial conditions for β-hemolytic streptococcus (Group A and other streptococcal infections).

ANY of the following

For the detection of a streptococcal infection causing respiratory illness, bacterial culture testing from a throat swab is reimbursable when the individual has a modified Centor criteria score of 3 or greater (Centor criteria includes tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough; each criterion = 1 point).
Bacterial culture testing from a throat swab is reimbursable when the individual is suspected of having bacterial pharyngitis in the absence of viral features (for example, cough, oral ulcers, rhinorrhea).
Bacterial culture testing from a throat swab is reimbursable following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent.
Blood culture testing for a streptococcal infection is reimbursable when individuals fail to demonstrate clinical improvement or have progressive symptoms/clinical deterioration after initiation of antibiotic therapy.
Blood culture testing is reimbursable in cases of suspected prosthetic joint infection.
For skin and/or soft tissue infections, bacterial culture testing for streptococcal infection from a skin swab or from pus is reimbursable.

Coverage notes

Coverage notes, exclusions, and policy update history.

ALL of the following

In cases of suspected viral pharyngitis, bacterial culture testing for streptococci from a throat swab is not reimbursable.
Except for asymptomatic children under age three with a mitigating circumstance (including a symptomatic family member), RADT is not reimbursable in the following situations: as a follow-up test to either a positive or negative bacterial culture; as a screening method in an asymptomatic patient; or in cases of suspected viral pharyngitis.
Except in cases of suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), serological titer testing (including anti-streptolysin O immunoassay) is not reimbursable.
The simultaneous coding for BOTH amplification and direct probe methods is not reimbursable.

Procedure and Billing Codes

Listed procedure codes (not exhaustive)CPT

86060
86063
86215
86317
86318
87040
87070
87071
87077
87081

1–10 of 18

1/2

No specific billing codes in excerptmixed

No codes listed

Code list completeness

CompletenessThe procedure code list provided is not all-encompassing; inclusion of a code does not guarantee coverage or reimbursement.

Number of codes listed in excerpt18 codes are listed in the policy excerpt (not exhaustive).

Coding guidanceProviders must follow standard coding guidelines and use HIPAA‑approved code sets; claims are subject to review against plan documents and contracts.

Provider Requirements and Billing Guidance

Documentation Required

Provider documentation and claims review requirements

Providers are responsible for submission of accurate documentation and claims for services performed. Submit complete, accurate documentation upon request; claims are subject to review and may be denied or adjusted if coding, clinical documentation, or benefit terms do not support the services billed.

Providers must submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.) and follow industry coding guidelines.
Claims are subject to code edit protocols and may be reviewed against benefit coverage, provider contract language, medical and clinical payment policies, and coding software logic.
Upon request, providers should furnish additional documentation to support medical necessity and billed services.

Denial Risk

Prior authorization / denial risk rules for RADT and serology

Prior authorization is not routinely required for RADT or serology by this policy, but claims for RADT and serological testing are at risk of denial when performed in non‑covered scenarios listed below. Verify member benefits and applicable plan documents; submit supporting documentation when testing falls into conditional coverage scenarios.

Clinical Definitions and References

Centor criteria — components and scoring

Centor componentsTonsillar exudates; tender anterior cervical lymphadenopathy; fever; absence of cough.

ScoringEach listed Centor criterion is worth one point (modified Centor scoring applies).

Use for reimbursementThroat culture may be reimbursable when modified Centor score ≥3 or when bacterial pharyngitis is suspected without viral features.

References and guideline sources

GAS pharyngitis guidelineInfectious Diseases Society of America clinical practice guideline for diagnosis and management of group A streptococcal pharyngitis (Shulman et al., 2012).

Skin and soft tissue infectionsIDSA Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections (Stevens et al., 2014).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policyβ-Hemolytic Streptococcus Testing reimbursement and coding policy

Policy CodePolicy CPCP LAB053

Change TypeClarified (administrative wording changes)

Effective DateSeptember 1, 2023

Next Review DateN/A

Key ActionSubmit accurate documentation and claims using HIPAA-approved code sets; claims may be reviewed and require additional documentation.

SourceLink

On This Page

The following tests are not reimbursable: panel tests that screen/identify multiple streptococcal strains (e.g., S. pyogenes [group A], S. agalactiae [group B], S. dysgalactiae [groups C/G], α-hemolytic streptococci) by immunoassay or nucleic-acid assays (e.g., Solana Strep Complete, Lyra Direct Strep); MALDI-TOF identification of streptococcus; quantification of any streptococcal strain using nucleic acid amplification (including PCR); hyaluronidase, streptokinase, nicotinamide-adenine dinucleotidease activity assays or corresponding anti-enzyme immunoassays (EXCEPT in suspected ARF or PSGN).

Anti-streptolysin O immunoassay is not reimbursable except in cases of suspected ARF or PSGN.

Policy Update History: 7/5/2023 — Document updated with literature review; Reimbursement Information revised for clarity only; references revised. 11/1/2022 — New policy.

RADT is NOT reimbursable except as noted: not reimbursable as a follow-up test to either a positive or negative bacterial culture; not reimbursable as a screening method in an asymptomatic patient; not reimbursable in cases of suspected viral pharyngitis. Exception: asymptomatic children under age three with a mitigating circumstance (including a symptomatic family member) may be considered.
RADT following a negative RADT in a symptomatic child or adolescent may be reimbursable when aligned with clinical guidance (see Reimbursement Information).
Serological titer testing is NOT reimbursable except in cases of suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN).
Simultaneous coding for BOTH amplification and direct probe methods is not reimbursable.
Verify prior authorization requirements and member-specific coverage; submit clinical documentation (symptoms, Centor score, reason for testing) to support medical necessity where testing is conditional.

Note

Reimbursement update note

Administrative reimbursement wording was revised for clarity; no change to coverage intentions. There is no new clinical information or change in coverage as of the effective date.

7/5/2023 update: Reimbursement Information revised for clarity only; no new information added.

Diagnostic assay evaluationsMulticenter and comparative studies of rapid molecular and antigen assays (e.g., Uphoff et al., 2016; Weinzierl et al., 2018) and reviews on streptococcal serology (Steer et al., 2015).