CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB051

Diagnostic Testing of Common Sexually Transmitted Infections

Reimbursement/payment criteria for laboratory testing of selected STIs (C. trachomatis, N. gonorrhoeae, T. pallidum, T. vaginalis, HSV, and HPV) for Blue Cross Blue Shield New Mexico members; providers must follow plan documents and coding rules and submit appropriate documentation and codes.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy CPCPLAB051

Change TypeRevised

Effective DateAug 15, 2023

Next Review Date

Key ActionSubmit accurate documentation and claims using valid HIPAA-approved code combinations and be prepared to provide additional documentation upon request to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and multitarget PCR testing for concurrent chlamydia and gonorrhea added as reimbursable when conditions are met.

6STI pathogens specifically covered by the policy

47+Procedure/CPT/HCPCS and miscellaneous codes listed

2023-08-15Plan effective date

Reimbursable Testing Criteria

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Reimbursable syphilis antibody testing

Conditions under which antibody testing for syphilis (Treponemal and nontreponemal) may be reimbursed.

ANY of the following

Asymptomatic person in a high-risk category: once a year assessment using either 'standard' or 'reverse' algorithm that includes initial and confirmatory tests for any initial positive (treponemal Ig AND nontreponemal test).
HIV-positive men or men who have sex with men (MSM): once every three months.
Person presenting with signs and/or symptoms of syphilis infection.
When a nontreponemal test is used as a test of cure (TOC) for a positive syphilis infection.

NOTE

Reimbursable syphilis screening for asymptomatic, not-high-risk individuals

Limited reimbursable scenarios for asymptomatic individuals not in high-risk groups.

ANY of the following

As part of newborn screening.
As part of follow-up in a victim of sexual assault.
Sexually active individuals less than 18 years of age (annually).

NOTE

Reimbursable NAAT/ PCR for chlamydia

When NAATs for Chlamydia trachomatis are reimbursable.

ANY of the following

Once a year assessment for asymptomatic person in a high-risk category.
Diagnosis for persons with signs/symptoms of chlamydial infection.
Diagnosis for suspected lymphogranuloma venereum (LGV).
Test of cure at least three months after initial chlamydial diagnosis.

NOTE

Limited chlamydia screening for asymptomatic, not-high-risk individuals

Scenarios where screening may be reimbursed for asymptomatic, not-high-risk persons.

ANY of the following

As part of newborn screening.
Follow-up of victim of sexual assault.
Sexually active individuals less than 18 years of age (annually).

NOTE

Reimbursable NAAT/ PCR for gonorrhea

When NAATs for Neisseria gonorrhoeae are reimbursable.

ANY of the following

Once a year assessment for asymptomatic person in a high-risk category.
Diagnosis for persons with signs/symptoms of gonorrheal infection.
As test of cure of treatment.

NOTE

Limited gonorrhea screening for asymptomatic, not-high-risk individuals

Scenarios where screening may be reimbursed for asymptomatic, not-high-risk persons.

ANY of the following

As part of newborn screening.
As part of follow-up of victim of sexual assault.
Sexually active individuals less than 18 years of age (annually).

NOTE

Multitarget PCR testing

When multitarget PCR (C. trachomatis and N. gonorrhoeae) is reimbursable.

ALL of the following

Individual meets the reimbursable conditions for both chlamydia and gonorrhea (then multitarget PCR testing with targets limited to C. trachomatis and N. gonorrhoeae may be reimbursable).

NOTE

HSV testing rules

Reimbursement criteria for herpes simplex virus testing.

ANY of the following

NAAT for HSV-1 or HSV-2 reimbursable for individuals with active genital ulcers or mucocutaneous lesions.
Type-specific serologic testing for HSV-2 (gG2) reimbursable for: recurrent/atypical genital symptoms with negative PCR/culture; clinical diagnosis of genital herpes with negative PCR/culture or without laboratory confirmation; or when patient's partner has genital herpes.
Immunoassay testing for HSV-1 or nonspecific herpes serology and screening of asymptomatic individuals for HSV-1/HSV-2 are not reimbursable.

NOTE

HPV testing rules

Reimbursement guidance for HPV testing.

ANY of the following

HR-HPV testing may be reimbursable when used in diagnosis/assessment of cancer or cancer therapy (e.g., p16 IHC or NAAT for HR-HPV).
HPV testing is NOT reimbursable for: screening for oncogenic HPV as part of general STI panel for asymptomatic patients; diagnosis of anogenital warts; screening for low-risk HPV types; or testing to determine HPV status in the general population.

NOTE

T. vaginalis testing rules

Reimbursement guidance for Trichomonas vaginalis testing.

ANY of the following

NAAT/PCR for T. vaginalis reimbursable for symptomatic individuals and asymptomatic individuals in high-risk groups (concurrent STI/history of STIs, high-prevalence settings such as STI clinics, individuals who exchange sex for payment).
Rapid identification by enzyme immunoassay is not reimbursable.

NOTE

Prohibited/Not reimbursable uses of nucleic acid quantitation

Tests not reimbursable when used for quantifying organism load.

ANY of the following

Using nucleic acid testing to quantify Chlamydia trachomatis, Neisseria gonorrhoeae, HSV-1, HSV-2, HPV, or Treponema pallidum is not reimbursable.

NOTE

Reimbursable testing related to PrEP

Baseline and periodic tests that may be reimbursable for individuals starting or on PrEP.

ANY of the following

Prior to beginning PrEP: baseline serum creatinine and estimated creatinine clearance, HIV antibody screening, HBV and/or HCV screening, pregnancy testing, and baseline STI screening per CDC.
On PrEP: HIV antibody test every 3 months; renal function at 3 months then up to every 6 months; NAAT screening for gonorrhea and chlamydia by anatomic site (every 3 months for MSM and individuals with child-bearing potential; 9 months after initiation then every 6 months for sexually active individuals); syphilis blood test (every 3 months for MSM and individuals with child-bearing potential; 9 months after initiation then every 6 months for sexually active individuals); pregnancy test every 3 months.

NOTE

Defined Terms

High-risk (for chlamydia/gonorrhea/syphilis)

High-risk (for chlamydia/gonorrhea/syphilis)Lists of high-risk characteristics per CDC and cited literature include: men who have sex with men (MSM); HIV-positive status; multiple or new sex partners; exchanging sex for money or drugs (sex work/transactional sex); attendance at STD/STI clinics; incarceration or living in detention facilities; younger sexually active persons (adolescents initiating sex) and other social risk factors such as unstable housing, substance use, or barriers to healthcare.

Examples in pregnant individualsDuring pregnancy, risk factors that increase syphilis risk include HIV-positive status, multiple sex partners, drug use or transactional sex, late or no prenatal care, incarceration, and unstable housing.

Adolescent-specific risksFor sexually active children and adolescents under 18, CDC-defined risks include early initiation of sex, STD clinic attendance, commercial sex exploitation, multiple or concurrent partners, inconsistent barrier protection, lower socioeconomic status, and coexisting disabilities or substance/mental health disorders.

Test of Cure (TOC)

Test of Cure (TOC)Use of a nontreponemal test for syphilis or a nucleic acid amplification test (NAAT) to confirm eradication of infection after treatment when specified by the policy; timing varies by organism (e.g., syphilis TOC uses nontreponemal tests; chlamydia TOC is at least three months after initial diagnosis).

Syphilis TOC methodWhen a nontreponemal test is used as a test of cure for a positive syphilis infection as described in the policy.

Chlamydia TOC timingNAAT as test of cure of treatment is reimbursable at least three months after the initial chlamydial diagnosis.

Policy Background and Scope

This policy defines Blue Cross Blue Shield of New Mexico reimbursement and payment criteria for laboratory testing of selected sexually transmitted infections (STIs). It applies to testing for C. trachomatis, N. gonorrhoeae, Treponema pallidum (syphilis), Trichomonas vaginalis, herpes simplex virus (HSV‑1 and HSV‑2), and human papillomavirus (HPV) for BCBSNM members and is effective as of 2023‑08‑15. Providers must review specific plan documents for member eligibility and product‑specific applicability because not all requirements apply to every product or contract (see plan documents and provider contract language).

Reimbursement is limited to the clinical and administrative scenarios described in the policy. Providers are responsible for submitting accurate documentation and valid HIPAA‑approved codes for services performed and should comply with industry coding guidelines; claims are subject to code edit protocols and may be reviewed or audited, and additional documentation may be requested to support a claim.

The policy summarizes when tests are considered reimbursable versus not reimbursable. Examples include: antibody testing for syphilis when used for screening or diagnosis in specified high‑risk groups or symptomatic persons; NAAT/PCR testing for chlamydia and gonorrhea in high‑risk or symptomatic individuals, or as test‑of‑cure when specified; NAAT for HSV from active genital ulcers; NAAT/PCR for T. vaginalis for symptomatic persons and select high‑risk asymptomatic groups; and HPV testing only when used in the diagnosis or assessment of cancer or cancer therapy. Several uses are explicitly excluded from reimbursement, including PCR/NAAT to quantify organism load and certain rapid immunoassays.

The policy also includes provider obligations and related operational notes: follow plan and coding rules, submit claims using appropriate CPT/HCPCS codes, and consult related policies for overlapping topics (for example, vaginitis multitarget PCR testing, prenatal screening, HIV, and cervical cancer screening). A material clarification in the August 15, 2023 update added that multitarget PCR testing targeting only C. trachomatis and N. gonorrhoeae may be reimbursable when the individual meets reimbursable conditions for both infections.

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OpenPayer

Diagnostic Testing of Common Sexually Transmitted Infections

Reimbursable Testing Criteria

Procedure and Lab Codes Referenced

Billing, Documentation, and Plan Requirements

Defined Terms

Policy Background and Scope

Policy Update History

Diagnostic Testing of Common Sexually Transmitted Infections

Reimbursable Testing Criteria

Procedure and Lab Codes Referenced

Billing, Documentation, and Plan Requirements

Defined Terms

Policy Background and Scope

Also Review

Policy Update History