ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB027

Testing for Diagnosis of Active or Latent Tuberculosis

This reimbursement policy defines laboratory testing and reimbursement criteria for diagnosis and screening of active and latent tuberculosis for Blue Cross Blue Shield of New Mexico members; it applies to providers submitting claims to BCBSNM and is subject to plan document and provider contract terms.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLAB027

Change TypeAdded NAATcodes added and removedterminology clarified

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit accurate documentation with claims and provide additional documentation upon request; ensure coding reflects updated procedure code list including added NAAT codes.

SourceLink

POLICY UPDATE CHANGES

Added to #2: Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M. tuberculosis, and M. avium complex.

Removed codes 87149, 87550, 87555, 87560 from the procedure code list.

Replaced 'Hologic Amplified MTD' with 'NAAT' for clarity in the molecular testing description.

Added codes 87564 and 0574U to the included code list.

Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M tuberculosis, and M. avium complex was added to reimbursement information.

Codes 87149, 87550, 87555, 87560 were removed from the policy.

HCPCS/CPT codes 87564 and 0574U were added.

Updated naming from 'M. avium intracellulare' to 'M. avium complex' to align with naming conventions.

Replaced 'Hologic Amplified MTD' with 'NAAT' for clarity in test descriptions.

10+tests referenced

~30procedure codes listed

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09/26/2025latest update

Coverage and Medical Necessity Criteria

Reimbursement criteria for TB testing

Reimbursement determinations for TB testing include the following covered and excluded items and clinical conditions.

IGRA may be reimbursable to diagnose or screen for latent tuberculosis (TB) infection in individuals at risk for Mycobacterium tuberculosis infection or when screening is required by law.

For all suspected TB infections, the following tests may be reimbursable: (a) Acid fast bacilli (AFB) smear/stain; (b) Culture and culture-based drug susceptibility testing of Mycobacteria spp.; (c) Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M. tuberculosis, and M. avium complex.

ALL of the following

The individual has been treated for TB in the past.
The individual was born in or has lived for at least 1 year in a foreign country with at least a moderate TB incidence (≥20 per 100,000) or a high primary multi-drug resistant (MDR) TB prevalence (≥2%).
The individual is a contact of an individual with MDR-TB.
The individual is HIV infected.

ALL of the following

Sputum cultures remain positive after 3 months of treatment.
Bacteriological reversion from negative to positive occurs.

For suspected extrapulmonary TB with pleural effusion, pericardial effusion, ascites, or other fluids, cell counts, protein, glucose, and lactate dehydrogenase (LDH) concentrations of cerebrospinal, pleural, peritoneal, pericardial, and other relevant fluids may be reimbursable.

In HIV‑infected individuals with CD4 cell counts ≤100 cells/µL who have signs or symptoms of tuberculosis, urine-based LAM testing may be reimbursable.

For individuals with active tuberculosis, interferon gamma release assay (IGRA) is not reimbursable.

Quantitative nucleic acid testing for Mycobacterium spp., M. tuberculosis, and M. avium complex is not reimbursable.

Testing of adenosine deaminase (ADA) and interferon‑gamma (IFNγ) levels in cerebrospinal, pleural, peritoneal, pericardial, and other fluids for diagnosis of extrapulmonary TB is not reimbursable.

Testing of serum protein biomarkers or panels of biomarkers for detection and diagnosis of TB is not reimbursable.

Reimbursement criteria for molecular-based drug susceptibility testing (historic and referenced)

History notes indicate criteria for when molecular-based drug susceptibility testing may be reimbursable include prior TB treatment, birth or extended residence in higher TB incidence countries, contact with MDR-TB, or HIV infection.

Prior TB treatment: molecular-based drug susceptibility testing may be reimbursable for individuals whose sputum is AFB smear positive or NAAT positive if the individual has previously been treated for TB.

Birth or extended residence in a higher-incidence country: molecular-based drug susceptibility testing may be reimbursable when the individual was born in or has lived ≥1 year in a foreign country with TB incidence ≥20 per 100,000 or MDR‑TB prevalence ≥2%.

Contact with MDR-TB case: molecular-based drug susceptibility testing may be reimbursable when the individual is a contact of someone with MDR‑TB.

HIV infection: molecular-based drug susceptibility testing may be reimbursable when the individual is HIV infected.

Procedure and Billing Codes

Listed procedure codes (not exhaustive)mixed

81099
82945
83520
83615
84157
84311
86480
86481
87070
87077

1–10 of 29

1/3

Codes added and removed in recent updatemixed

87564	Qualitative NAAT (added)
0574U	Molecular/NAAT related code (added)
87149	Removed code (previously listed)
87550	Removed code (previously listed)
87555	Removed code (previously listed)
87560	Removed code (previously listed)

Provider Documentation, Billing, and Action Items

Documentation Required

Provider documentation and claims submission

Providers are responsible for submitting accurate documentation and coding for services rendered. Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.) and follow industry standard coding guidelines (UB, AMA CPT Assistant, CMS NCCI, CCI edits). Claims are subject to code-edit protocols and clinical review against benefit terms, provider contract language, medical policies, and coding policies. Upon request, provide additional clinical documentation to support medical necessity and coding.

Ensure medical record documentation supports test ordered, clinical indication, specimen source, and result interpretation.
Include supporting clinical notes when billing molecular or NAAT testing for Mycobacteria to demonstrate indication (e.g., symptoms, exposure risk, HIV status, prior TB treatment).
Providers may be asked to submit lab reports, culture results, AFB smear results, and prior treatment history during claim review or appeal.

Prior Authorization

Prior authorization / clinical criteria (operational guidance)

Key Terms and Test Definitions

inv-08: IGRA — define Interferon gamma release assay (IGRA)

TermInterferon gamma release assay (IGRA)

PurposeLaboratory assay to diagnose or screen for latent tuberculosis (TB) infection.

When reimbursableMay be reimbursable to diagnose or screen for latent TB in individuals at risk for Mycobacterium tuberculosis infection or when screening is required by law.

When not reimbursableNot reimbursable for individuals with active tuberculosis.

Related testsIGRA is distinct from AFB smear/stain, culture, NAAT, and drug susceptibility testing referenced elsewhere in the policy.

inv-09: NAAT — define nucleic acid amplification testing for Mycobacteria spp., M. tuberculosis, and M. avium complex

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLAB027

Change TypeAdded NAATcodes added and removedterminology clarified

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit accurate documentation with claims and provide additional documentation upon request; ensure coding reflects updated procedure code list including added NAAT codes.

SourceLink

On This Page

Policy updates (09/26/2025 and prior) added qualitative NAAT for Mycobacteria spp., M. tuberculosis, and M. avium complex and clarified molecular testing language; direct probe testing items were removed as not available.

Policy update context

Prior authorization is not generally required for routine TB diagnostic testing per this policy; however, tests that are not reimbursable (see billing/coding callout) will be denied. Use clinical criteria below to determine medical necessity before submitting claims for molecular-based drug susceptibility testing.

Molecular-based drug susceptibility testing (reimbursable) — only when ANY of the following apply: prior TB treatment; born in or lived ≥1 year in a country with TB incidence ≥20/100,000 or MDR-TB prevalence ≥2%; contact of a person with MDR-TB; HIV infection.
Repeat drug susceptibility testing may be reimbursable when: sputum cultures remain positive after 3 months of treatment, or bacteriological reversion from negative to positive.
Urine LAM testing may be reimbursable for HIV-infected individuals with CD4 ≤100 cells/µL who have signs/symptoms of TB.

Billing Rule

Reimbursement updates — tests and codes

Billing and reimbursement updates — review codes and coverage before billing to avoid denials.

Covered tests and clinical notes should align with policy: AFB smear/stain; culture and culture-based drug susceptibility testing for Mycobacteria spp.; qualitative NAAT for Mycobacteria spp., M. tuberculosis, and M. avium complex (added 09/26/2025).
NAAT (qualitative) now replaces direct probe/direct amplified probe tests that are no longer available — direct probe testing removed from coverage list.
Added CPT/PLA codes: 87564 and 0574U (effective 09/26/2025).
Removed codes (no longer valid/covered for direct probe testing): 87149, 87550, 87555, 87560.
Not reimbursable: IGRA for individuals with active tuberculosis; quantitative NAAT for Mycobacterium spp., M. tuberculosis, and M. avium complex; ADA and IFN-γ levels in body fluids for extrapulmonary TB diagnosis; serum protein biomarker panels for TB detection/diagnosis.

TermNucleic acid amplification testing (NAAT)

ScopeQualitative NAAT for Mycobacteria spp., Mycobacterium tuberculosis, and Mycobacterium avium complex.

When reimbursableMay be reimbursable for suspected TB infections as part of diagnostic testing (listed with AFB smear/stain and culture).

Policy changesPolicy update replaced specific 'Hologic Amplified MTD' terminology with the general NAAT term and explicitly added qualitative NAAT to reimbursable tests.

LimitationsQuantitative NAAT for Mycobacterium spp., M. tuberculosis, and M. avium complex is not reimbursable.

inv-10: LAM — define lipoarabinomannan (LAM) urine-based detection

TermLipoarabinomannan (LAM)

MethodUrine-based detection of mycobacterial cell wall glycolipid (lipoarabinomannan).

When reimbursableMay be reimbursable in HIV-infected individuals with CD4 cell counts ≤100 cells/µL who have signs and symptoms of tuberculosis.

Clinical contextUsed as a point-of-care urine test to aid diagnosis of TB in severely immunocompromised persons (per policy applicability).

Related exclusionsOther biomarker panels and certain fluid biomarker tests (e.g., ADA, IFNγ in fluids) are not reimbursable per policy.

inv-11: Qualitative NAAT for Mycobacteria spp., M. tuberculosis, and M. avium complex — redundant/alternate NAAT definition entry

TermQualitative NAAT for Mycobacteria spp., M. tuberculosis, and M. avium complex

DefinitionQualitative nucleic acid amplification testing that detects presence (but not quantity) of Mycobacteria spp., M. tuberculosis, and M. avium complex.

Reimbursement statusListed as a reimbursable diagnostic test for suspected TB infections alongside AFB smear/stain and culture.

Policy historyAdded to the reimbursable tests in the 09/26/2025 policy update; this change led to removal of older direct probe testing entries and terminology updates.

Related limitQuantitative NAAT is specifically noted as not reimbursable (policy distinguishes qualitative vs quantitative NAAT).