ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB045

Pathogen Panel Testing (CPCPLAB045)

Reimbursement and coding policy for multiplex/molecular pathogen panel testing in outpatient settings for Blue Cross Blue Shield of New Mexico members; defines reimbursable and non-reimbursable panel types and associated coding guidance.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPathogen Panel Testing

Policy CodePolicy CPCPLAB045

Change TypeRevised examples and reimbursement guidance

Effective DateNovember 1, 2023

Next Review DateN/A

Key ActionSubmit accurate documentation and supporting records with claims; providers may be asked to supply additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Removed a reimbursement exclusion that disallowed molecular-based panel testing for general screening of microorganisms (examples: SmartJane™, UroSwab®) from the Reimbursement Information section and replaced it with updated examples.

Added GENETWORx Molecular PCR UTI Test and GENETWORx PCR Wound Testing as examples and added an explicit non-reimbursable example (MicroGenDX qPCR+NGS).

Document updated with literature review.

up to 5max reimbursable respiratory pathogens

6+non-reimbursable respiratory panels

multiplenon-reimbursable outpatient panel uses

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procedure codes listed

2023-07-17last document update

3examples added/removed

Outpatient Coverage and Reimbursement Rules

Outpatient coverage criteria

Covered when ALL of the following apply:

ALL of the following

At least one qualifying sign or symptom
- Temperature ≥ 102° F
- Pronounced dyspnea
- Tachypnea
- Tachycardia
Multiplex PCR-based panel testing of up to 5 respiratory pathogens may be reimbursable when the patient is displaying the qualifying signs or symptoms described above
Multiplex PCR-based panel testing of 6 or more respiratory pathogens is not reimbursable in the outpatient setting
Non-reimbursable even if respiratory signs/symptoms present
Multiplex PCR-based panel testing of pathogens in cerebrospinal fluid (CSF) is not reimbursable in the outpatient setting
Molecular detection–based panel testing of pathogens in the blood is not reimbursable in the outpatient setting
Molecular detection–based panel testing of urine pathogens for diagnosis of urinary tract infections (e.g., GENETWORx Molecular PCR UTI Test) is not reimbursable in the outpatient setting
Molecular-based panel testing to screen for or diagnose wound infections (e.g., GENETWORx PCR Wound Testing) is not reimbursable in the outpatient setting
Molecular-based panel testing for general screening of microorganisms (e.g., MicroGenDX qPCR+NGS) is not reimbursable in the outpatient setting

Reimbursement Information updates

Summary of reimbursement information changes and examples of tests that were added or removed in the policy update.

ALL of the following

The Reimbursement Information section was updated to remove a prior blanket example list that characterized certain molecular-based panel testing of vaginal swabs and urine samples (e.g., SmartJane™, UroSwab®) as non-reimbursable and to replace that language with clarified examples.
GENETWORx Molecular PCR UTI Test was added as an example in the urine/UTI non-reimbursable category.
GENETWORx PCR Wound Testing was added as an example in the wound testing non-reimbursable category.
An explicit non-reimbursable example was added for molecular-based general screening of microorganisms: MicroGenDX qPCR+NGS.

Procedure Codes and Coding Rules

Listed procedure codes (not exhaustive; inclusion does not guarantee coverage)mixed

87154
87483
87631
87632
87633
87636
87637
0068U
0086U
0109U

1–10 of 25

1/3

Examples mentioned in reimbursement sectionmixed

No codes listed

Respiratory multiplex panel reimbursement threshold

Outpatient respiratory multiplex reimbursementUp to 5 respiratory pathogens in a multiplex PCR panel may be reimbursable for outpatient encounters when clinical signs/symptoms are present; panels of 6 or more respiratory pathogens are not reimbursable in the outpatient setting.

Clinical trigger examplesReimbursable testing applies when individuals display signs/symptoms of respiratory tract infection including at least one: temperature ≥102°F, pronounced dyspnea, tachypnea, or tachycardia.

Scope limitationThreshold applies specifically to outpatient multiplex PCR-based respiratory pathogen panels.

Policy revision count

Document update summaryPolicy updated 7/17/2023 with a literature review and specific reimbursement examples added and removed in the Reimbursement Information section.

Documentation, Claim Submission, and Provider Notices

Documentation Required

Provider responsibilities for documentation and claims

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and code combinations and code appropriately according to industry standard coding guidelines, including but not limited to UB editor, AMA CPT/CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG guidelines, CMS NCCI Policy Manual, CCI table edits and other CMS guidelines. Claims are subject to code edit protocols and review for benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit any additional documentation to support medical necessity and claim adjudication.

Submit complete medical records and supporting documentation when requested (e.g., test reports, clinical notes, laboratory requisitions).
Use correct and specific codes; avoid unlisted or generic codes when a specific code exists.
Follow CMS and BCBSNM billing guidance for modifier use and code bundling (NCCI/CCI edits).
Attach required reports or attachments per plan/contract or as requested to facilitate review.

Definitions and Policy Scope

Pathogen Panel Testing (CPCPLAB045)

Policy identifierPathogen Panel Testing (CPCPLAB045), Version 1.0; Enterprise CPCP Committee approval date July 17, 2023; Plan effective date November 1, 2023.

Governing scopeReimbursement and coding policy for multiplex/molecular pathogen panel testing in outpatient settings for BCBSNM members; defines reimbursable and non-reimbursable panel types and coding guidance.

Authority and applicabilityIf conflicts arise, plan documents or provider contracts govern; BCBSNM may exercise discretion in policy interpretation and application.

Supporting references

Selected supporting referencesQIAstat-Dx product information (Qiagen) and evaluations of multiplex PCR assays (e.g., QIAstat-Dx, FilmArray) referenced for diagnostic performance and utility.

Clinical impact studies

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPathogen Panel Testing

Policy CodePolicy CPCPLAB045

Change TypeRevised examples and reimbursement guidance

Effective DateNovember 1, 2023

Next Review DateN/A

Key ActionSubmit accurate documentation and supporting records with claims; providers may be asked to supply additional documentation upon request.

SourceLink

On This Page

Document updated with literature review as part of the 7/17/2023 revision.

Examples changedRemoved prior blanket exclusion language for molecular-based general screening panels and added examples such as GENETWORx Molecular PCR UTI Test and GENETWORx PCR Wound Testing; explicitly listed MicroGenDX qPCR+NGS as non-reimbursable.

Revision history entriesOriginal policy issued 11/1/2022; material update recorded 7/17/2023 (document updated with literature review).

Billing Rule

Reimbursement update and provider implications

Reimbursement language updated: BCBSNM removed the prior blanket non-reimbursement statement for molecular-based general screening panels and replaced it with more targeted reimbursement guidance and examples. Providers should note the policy changes and billing implications when submitting claims for molecular panel testing.

Effective 7/17/2023 update: removed broad 'not reimbursable' language for molecular-based general screening panels and added specific examples and exceptions.
Examples added or clarified include GENETWORx Molecular PCR UTI Test and GENETWORx PCR Wound Testing.
Molecular-based panel testing for general screening of microorganisms (e.g., MicroGenDX qPCR+NGS) is specifically identified as not reimbursable where applicable — verify policy criteria and coding guidance before billing.
When in doubt, submit documentation demonstrating medical necessity and contact BCBSNM for prior clarification or claim review.

Multiple studies on PCR testing impact cited (e.g., impact on management of enteroviral meningitis; rapid PCR for respiratory pathogens and resource utilization in pediatrics).

Guidelines and reviewsSurviving Sepsis Campaign, IDSA encephalitis management, and systematic reviews/meta-analyses of multiplex panels (e.g., Biofire FilmArray) are listed as supporting literature.