ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB051

Diagnostic Testing of Common Sexually Transmitted Infections

This policy governs reimbursement criteria for laboratory testing of selected STIs (C. trachomatis, N. gonorrhoeae, T. pallidum, T. vaginalis, HSV, and HPV) for Blue Cross Blue Shield of New Mexico products and describes applicable situations and limitations for reimbursement.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy CPCPLAB051

Change TypeMaterial additions and revisions to reimbursement criteria and code list

Effective DateSep 26, 2025

Next Review DateN/A

Key ActionSubmit claims with appropriate documentation and valid HIPAA-approved codes; follow updated reimbursement criteria for qualitative NAAT and specified screening intervals.

SourceLink

POLICY UPDATE CHANGES

Added the adjective 'qualitative' to 'NAAT' in multiple numbered reimbursement items to clarify test type.

Added specific situations where qualitative NAAT for Trichomonas vaginalis may be reimbursable, including symptomatic individuals, follow-up testing ≥3 months after diagnosis, annual screening for high-risk asymptomatic individuals, annual screening for asymptomatic individuals with HIV, and as part of sexual assault follow-up.

Revised guidance for STI screening while on or prior to PrEP to specify frequency and tests (qualitative NAAT for gonorrhea and chlamydia and serologic syphilis testing) with different intervals for MSM versus sexually active individuals.

Revised reimbursement statement to indicate 'Direct probe detection and/or quantitative NAAT' and adjusted CPT/HCPCS/other codes (added 87626, 87800; removed multiple older codes).

Added treponemal and nontreponemal testing once prior to allogeneic hematopoietic stem cell transplantation as part of pre-transplant assessment for donors and recipients.

Added reimbursement guidance distinguishing Mycoplasma genitalium testing: NAAT may be reimbursable for symptomatic individuals but not reimbursable for asymptomatic screening.

Stated that nucleic acid testing to determine antimicrobial susceptibility in N. gonorrhoeae or macrolide resistance in M. genitalium is not reimbursable.

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.

24reimbursement items

>30codes listed (partial)

~10code changes examples

Annual / 3-mo / 6-moscreening intervals noted

Reimbursement Criteria and Limits

Reimbursement criteria by organism and situation

Reimbursement criteria, allowed uses, and non‑reimbursable tests for the specified organisms (CT, NG, TP, TV, HSV, HPV) and related situations.

ALL of the following

ANY of the following
- Asymptomatic persons in a high‑risk category: once yearly using a standard or reverse algorithm that includes initial and confirmatory tests (treponemal Ig test AND a nontreponemal test).
- Diagnosis of persons presenting with signs and/or symptoms of syphilis (see policy notes for symptom examples).
- HIV‑positive men or men who have sex with men (MSM): testing once every three months.
- Pre‑transplant assessment (allo‑HCT donors and recipients): treponemal Ig and nontreponemal testing once prior to transplant.
- When a nontreponemal test is used as a test‑of‑cure (TOC) for a previously positive syphilis infection.
Not reimbursable: PCR or other nucleic acid amplification testing (NAAT) for syphilis.

ALL of the following

ANY of the following
- Once yearly for asymptomatic persons in a high‑risk category.
- Diagnosis of persons presenting with signs and/or symptoms of chlamydial infection.
- Diagnosis of suspected lymphogranuloma venereum (LGV).
- Test‑of‑cure at least three months after initial chlamydial diagnosis.
Not reimbursable: serologic testing for chlamydia or LGV.

ALL of the following

ANY of the following
- Once yearly for asymptomatic persons in a high‑risk category.
- Diagnosis of persons presenting with signs and/or symptoms of gonorrheal infection.
- As a test‑of‑cure following treatment when indicated.
Culture testing to determine antimicrobial susceptibility may be reimbursable for individuals who do not respond to initial treatment.
Not reimbursable: nucleic acid testing to determine antimicrobial susceptibility for N. gonorrhoeae (see policy for allowed culture‑based susceptibility testing conditions).

ALL of the following

ANY of the following
- Symptomatic individuals.
- Follow‑up testing a minimum of three months after initial trichomoniasis diagnosis.
- Annual screening for asymptomatic individuals belonging to a high‑risk group.
- Annual screening for asymptomatic individuals who have HIV.
- As part of follow‑up in a victim of sexual assault.
Not reimbursable: rapid enzyme immunoassay identification of Trichomonas.

ALL of the following

Qualitative NAAT testing may be reimbursable for symptomatic individuals.
Not reimbursable: screening of asymptomatic individuals using NAAT.
Not reimbursable: nucleic acid testing to determine macrolide resistance (molecular resistance testing) for M. genitalium.

ALL of the following

Qualitative NAAT for HSV‑1 or HSV‑2 reimbursable for individuals with active genital ulcers or mucocutaneous lesions.
ANY of the following
- Recurrent or atypical genital symptoms or lesions with a negative HSV PCR or culture result.
- Clinical diagnosis of genital herpes when PCR or culture are negative or without laboratory confirmation.
- When an individual's partner has genital herpes.
Not reimbursable: immunoassay testing for HSV‑1 or non‑specific HSV typing; screening of asymptomatic individuals for HSV‑1 or HSV‑2.

ALL of the following

Prior to beginning a PrEP regimen: hepatitis B triple panel testing (HBsAg, anti‑HBs, total anti‑HBc) may be reimbursable.
ANY of the following
- Qualitative NAAT screening for gonorrhea and chlamydia: once every three months for MSM; once every six months for sexually active individuals.
- Blood testing to screen for syphilis: once every three months for MSM; once every six months for sexually active individuals.

ALL of the following

Direct probe detection and/or quantitative NAAT for the following organisms is not reimbursable: Chlamydia trachomatis, Neisseria gonorrhoeae, HSV‑1, HSV‑2, Human papillomavirus, and Treponema pallidum.
Nucleic acid testing to determine antimicrobial susceptibility in N. gonorrhoeae or to detect macrolide resistance in M. genitalium is not reimbursable.

Reimbursement criteria and limits (excerpt)

Selected reimbursable and non‑reimbursable laboratory testing rules and limits captured in this excerpt.

ALL of the following

ANY of the following
- Symptomatic individuals.
- Follow‑up testing at least three months after initial trichomoniasis diagnosis.
- Annual screening for asymptomatic individuals in a high‑risk group.
- Annual screening for asymptomatic individuals with HIV.
- As part of follow‑up in a victim of sexual assault.

Procedure and Billing Codes

Example listed procedure/CPT/HCPCS codes (partial list)mixed

86592
87491
87623
G0499

Selected STI laboratory codesmixed

86592
87491
87623
0064U	proprietary molecular assay U-code
G0499

recently added codesCPT | HCPCS | NOC

87626	Added to allowed code list (document states 87626 added)
87800	Added to allowed code list (document states 87800 added)
87563	Added (listed in update history)
0402U	Added (listed in update history)
0455U	Added (listed in update history)
0463U	Added (listed in update history)
0483U	Added (listed in update history)
0484U	Added (listed in update history)

recently removed codes (examples)CPT | HCPCS

82565	Removed from code list (document states removed)
82575	Removed from code list
84702	Removed from code list
86701	Removed from code list
87660	Removed from code list
0500T	Removed from code list

Reimbursement frequency examples

Annual screeningAnnual screening for asymptomatic individuals in specified high-risk groups (see Notes) is reimbursable for certain organisms (example: syphilis, Trichomonas in high-risk groups).

Every 3 monthsOnce every three months reimbursement interval specified for HIV-positive men or men who have sex with men (MSM) for syphilis screening; also q3 months for PrEP-related gonorrhea/chlamydia/syphilis screening in MSM.

Every 6 monthsOnce every six months reimbursement interval specified for sexually active individuals for PrEP-related gonorrhea/chlamydia/syphilis screening.

Follow-up minimum intervalFollow-up qualitative NAAT testing for Trichomonas vaginalis may be reimbursable at a minimum of three months after initial diagnosis.

Code list completeness

Documentation, Billing, and Provider Notices

Documentation Required

Documentation and Claim Review

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims with supporting clinical documentation upon request. Claims are subject to review, including benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should furnish additional documentation to support medical necessity, diagnosis, specimen source, testing indications, and any other information required for claim adjudication.

Submit accurate and complete medical records and lab reports when requested
Be prepared for retrospective claim review and requests for additional documentation

Billing Rule

Coding/Billing Requirements

Claims must be submitted using valid HIPAA-approved code sets and coded in accordance with industry-standard coding guidelines (e.g., AMA CPT, HCPCS, ICD-10-CM/PCS, NDC, Uniform Billing, CMS NCCI). Claims are subject to coding reviews and code-edit protocols. Use correct code combinations, modifiers, and units; improper coding may result in denial or recoupment. Providers should follow payer-specific billing instructions and include supporting documentation when billing for STI-related laboratory services.

Terms, Risk Groups, and References

High-risk individuals for STI screening

High-risk: generalHigh-risk individuals vary by organism; policy refers to organism-specific notes (Notes 1–9) for detailed risk-factor lists used to define high-risk groups eligible for annual screening.

Syphilis high-risk examplesIncludes asymptomatic persons in high-risk categories and HIV-positive MSM (who may qualify for screening more frequently, e.g., every 3 months).

Trichomonas high-riskAnnual screening reimbursable for asymptomatic individuals who belong to a high-risk group and annual screening for people with HIV, per Trichomonas reimbursement rules.

Organism-specific variationPolicy scope covers CT, NG, TP, TV, HSV, and HPV; high-risk definitions and screening frequency differ across organisms and are detailed in the notes referenced in the policy.

Syphilis symptomatic findings

Primary lesions

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy CPCPLAB051

Change TypeMaterial additions and revisions to reimbursement criteria and code list

Effective DateSep 26, 2025

Next Review DateN/A

Key ActionSubmit claims with appropriate documentation and valid HIPAA-approved codes; follow updated reimbursement criteria for qualitative NAAT and specified screening intervals.

SourceLink

On This Page

ALL of the following

May be reimbursable for symptomatic individuals.
Not reimbursable for screening asymptomatic individuals; molecular testing to determine macrolide resistance is not reimbursable.

ALL of the following

Nucleic acid testing to determine antimicrobial susceptibility in Neisseria gonorrhoeae or macrolide resistance in M. genitalium is not reimbursable.

ALL of the following

Prior to beginning PrEP: hepatitis B triple panel testing (HBsAg, anti‑HBs, total anti‑HBc) may be reimbursable.
ANY of the following
- Qualitative NAAT screening for gonorrhea and chlamydia: once every three months for MSM; once every six months for sexually active individuals.
- Blood testing to screen for syphilis: once every three months for MSM; once every six months for sexually active individuals.

ALL of the following

Treponemal Ig and nontreponemal testing once prior to transplant for both donors and recipients may be reimbursable as part of pre‑transplant assessment.

ALL of the following

Policy language updated to reference 'direct probe detection and/or quantitative NAAT' as not reimbursable for listed organisms; consult the policy code list for recent additions and removals of procedure codes.

CPT/HCPCS examplesPolicy lists a broad set of procedure codes used for STI testing including examples such as 86592, 87491, 87623, G0499 among many others.

Proprietary U‑codesMultiple proprietary assay HCPCS U‑codes are included (examples in list: 0064U, 0065U, 0096U, 0210U, 0402U, 0455U, 0463U, 0483U, 0484U).

Nucleic acid and antigen codesCodes cover NAAT/ PCR and other molecular assays (examples: 87623-87626 series, 87800, 87797-87799).

Comprehensiveness noteDocument includes an extensive, non-exhaustive code list (~30+ codes in the excerpt) relevant to STI laboratory billing; consult full policy code list for complete billing guidance.

PrEP screening interval (MSM)

Interval (MSM)Qualitative NAAT screening for gonorrhea and chlamydia (and serologic syphilis testing) while on or prior to PrEP: once every 3 months for men who have sex with men (MSM).

Screening tests specifiedQualitative NAAT for gonorrhea and chlamydia plus blood testing for syphilis are the tests referenced for the q3-month interval in MSM.

ContextThis interval applies to screening prior to beginning or while an individual is undergoing a PrEP regimen for HIV prevention as described in the policy update history.

PrEP screening interval (sexually active individuals)

Interval (sexually active individuals)Qualitative NAAT screening for gonorrhea and chlamydia (and serologic syphilis testing) while on or prior to PrEP: once every 6 months for sexually active individuals (non-MSM).

Screening tests specifiedQualitative NAAT for gonorrhea and chlamydia plus blood testing for syphilis are the tests referenced for the q6-month interval.

ApplicabilityDescribed in the policy update history as the recommended frequency for sexually active individuals in the context of PrEP-related screening.

Use HIPAA-compliant CPT/HCPCS/ICD-10 codes and appropriate modifiers
Follow NCCI, CMS, and AMA coding guidance and payer-specific instructions
Include documentation to justify test(s) billed

Note

STI test codes

The following codes are referenced for STI testing and billing. This list includes commonly billed CPT and proprietary assay (Q-/U-) codes used for laboratory testing of sexually transmitted infections.

86592, 86593, 86631, 86632, 86694, 86695, 86696, 86704, 86706, 86780, 87081, 87110, 87181, 87340, 87490, 87491, 87492, 87528, 87529, 87530, 87563, 87590, 87591, 87592, 87623, 87624, 87625, 87626, 87661, 87797, 87798, 87799, 87800, 87808, 88341, 88342, 88344, 0064U, 0065U, 0096U, 0210U, 0402U, 0455U, 0463U, 0483U, 0484U, G0499

Prior Authorization

Trichomonas vaginalis qualitative NAAT reimbursement situations

Qualitative NAAT testing for Trichomonas vaginalis may be reimbursable in specific situations. When billing for T. vaginalis qualitative NAAT, ensure documentation supports one of the reimbursable scenarios and retain records of clinical indications, timing relative to prior diagnosis, and patient risk status.

Symptomatic individuals (document signs/symptoms consistent with Note 5)
Follow-up testing performed a minimum of three months after initial trichomoniasis diagnosis
Annual screening for asymptomatic individuals who are in a high-risk group (document risk factors)
Annual screening for asymptomatic individuals with HIV infection
As part of follow-up testing for a victim of sexual assault

Chancre (primary syphilis) is a key sign used in clinical decision-making for syphilis testing.

Rash and mucous lesionsSkin rash and/or mucous membrane lesions in mouth, vagina, anus, hands, and feet (secondary syphilis) are listed symptomatic findings.

Neurologic and ocular signsSigns of neurosyphilis (severe headache, muscle weakness, numbness, cognitive changes) and ocular syphilis (eye pain, visual changes) are included as symptomatic findings informing testing.

Other systemic symptomsSecondary symptomology can include fever, fatigue, sore throat, lymphadenopathy, weight loss, myalgias, headache, and hair loss.

Reference sources

CDC guidanceCDC Sexually Transmitted Infections Treatment Guidelines and disease-specific CDC pages (e.g., About Syphilis, About Chlamydia) are cited as core references.

UpToDate and specialty reviewsUpToDate topic reviews (screening for STIs, HPV, genital herpes) are cited as supporting clinical references in the policy.

FDA device and assay approvalsFDA PMN/510(k) and device/assay approvals (e.g., BD ONCLARITY HPV ASSAY, Xpert CT/NG PMN) are referenced for test/assay context and coding updates.

Qualitative NAAT — definition and context

Definition'Qualitative NAAT' is used in the policy to specify nucleic acid amplification tests that detect the presence (positive/negative) of target organisms rather than providing quantitative viral/bacterial load measurements.

Policy usage contextsPolicy adds the adjective 'qualitative' to NAAT in multiple reimbursement items (e.g., for Trichomonas vaginalis, gonorrhea, chlamydia, HSV lesion testing) to clarify applicable test type.

Reimbursement implicationsWhen the policy specifies 'qualitative NAAT', reimbursement is tied to those qualitative NAAT uses and situations described (symptomatic diagnosis, screening intervals, follow-up testing), not to quantitative NAAT or direct probe detection unless otherwise stated.

Triple panel hepatitis B testing

Panel componentsTriple panel hepatitis B testing consists of HBsAg (hepatitis B surface antigen), anti-HBs (hepatitis B surface antibody), and total anti-HBc (total antibody to hepatitis B core antigen).

PrEP and pre-transplant usePolicy states triple panel testing may be reimbursable prior to beginning a PrEP regimen and was added as once prior to allogeneic hematopoietic stem cell transplantation for donors and recipients.

Screening purposeUsed to screen for hepatitis B infection or immunity status as part of PrEP initiation or pre-transplant assessment per policy guidance.