CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO68

Onychomycosis Testing

Reimbursement criteria for laboratory testing to diagnose onychomycosis (nail fungus) for Blue Cross Blue Shield of New Mexico members; explains which tests may or may not be reimbursed and directs providers to plan documents for product-specific applicability.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOnychomycosis Testing

Policy CodePolicy CPCPLABO68

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be requested to provide additional documentation; reimbursement varies by product and plan documents govern applicability.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Direct microscopic/culture reimbursable

0Nucleic acid tests reimbursable

0ATR-FTIR reimbursable

0Sterol testing reimbursable

15+Referenced codes

Onychomycosis Testing Reimbursement Criteria

Onychomycosis testing reimbursement criteria

Reimbursement guidance for diagnostic testing of onychomycosis:

ALL of the following

ONE of
- Direct microscopic examination with potassium hydroxide may be reimbursable for individuals with onychomycosis.
- Fungal culture of desquamated subungual material may be reimbursable for individuals with onychomycosis.
- Fungal stain of a nail clipping(s) may be reimbursable for individuals with onychomycosis.
Nucleic acid tests (including but not limited to PCR, PCR-RFLP, and next-generation sequencing [NGS]) to screen for, diagnose, or confirm onychomycosis are not reimbursable.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOnychomycosis Testing

Policy CodePolicy CPCPLABO68

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be requested to provide additional documentation; reimbursement varies by product and plan documents govern applicability.

SourceLink

On This Page

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.

Provider Documentation and Plan Governance

Documentation Required

Submit accurate documentation; additional documentation may be requested and plan documents govern reimbursement

Providers are responsible for submitting accurate documentation of services performed and must code claims using valid HIPAA‑approved code sets and industry standard coding guidelines. Claims are subject to claim review, code edit protocols, and the terms of benefit coverage and provider contract; upon request providers should submit additional documentation to support the claim. Reimbursement and applicability of this policy may vary by product and, if a conflict exists, the member's plan document or provider contract will govern.

Use valid HIPAA‑approved code sets and follow standard coding guidelines (e.g., UB, CPT, HCPCS, ICD‑10, NDC, DRG, CMS/NCCI rules).
Claims are subject to code edit protocols, claim review, and provider contract/plan document terms.
Upon request, submit any additional documentation to support coverage and reimbursement.
If a conflict exists between this CPCP and a plan document or provider contract, the plan document or provider contract governs applicability.

Plan Documents and Test Definitions

Plan documents and provider responsibilities

Governing documentsPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents that govern conflicts with this policy.

Provider responsibilityProviders are responsible for submission of accurate documentation of services performed and may be asked to provide additional documentation upon request.

Conflict resolutionIf a conflict exists between this Clinical Payment and Coding Policy and a plan document, the plan document will govern; if a conflict exists with a provider contract, the provider contract governs.

Coding standardsClaims should be coded using HIPAA-approved code sets and industry-standard coding guidelines (e.g., CPT, HCPCS, ICD-10, NCCI).

Nucleic acid tests (PCR, PCR-RFLP, NGS)

DefinitionNucleic acid tests include PCR, PCR-RFLP, and next-generation sequencing (NGS) used to detect specified fungal organisms.

Reimbursement stanceNucleic acid tests (including PCR, PCR-RFLP, NGS) to screen for, diagnose, or confirm onychomycosis are not reimbursable.

Examples of microorganisms testedIncludes testing for Candida spp., Aspergillus spp., Trichophyton rubrum, T. mentagrophytes, Epidermophyton floccosum, Neoscytalidium dimidiatum, Onychocola canadensis, Scopulariopsis spp., Alternaria spp., Acremonium spp., and Fusarium spp.

Note referenceSee Note 1 in Reimbursement Information for the list of microorganisms evaluated by nucleic acid testing in this policy.

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OpenPayer

Onychomycosis Testing

Onychomycosis Testing Reimbursement Criteria

Referenced Laboratory and Pathology Codes

Provider Documentation and Plan Governance

Plan Documents and Test Definitions