ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB027

Testing for Diagnosis of Active or Latent Tuberculosis

Reimbursement criteria for laboratory testing to diagnose or screen for active and latent tuberculosis for Blue Cross Blue Shield of New Mexico members; applies to providers submitting claims to BCBSNM under applicable plan documents.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLAB027

Change TypeCoding updates and NAAT added to reimbursement guidance

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit accurate documentation upon request; claims are subject to plan documents, provider contracts, medical and coding policies, and code edit protocols.

SourceLink

POLICY UPDATE CHANGES

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

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

Codes 87564 and 0574U were added to the policy coding list.

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

Reference to 'Hologic Amplified MTD' was replaced with 'NAAT' for clarity.

30+Procedure codes enumerated

2new CPT/HCPCS codes added

4codes removed

Conditional

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IGRA reimbursable stance

Not reimbursedQuantitative NAAT

Coverage Criteria for TB Testing

TB testing coverage criteria

Reimbursable and non-reimbursable TB testing under the Plan:

Interferon gamma release assay (IGRA) reimbursable for: (a) individuals at risk for Mycobacterium tuberculosis infection; OR (b) individuals who are unlikely to be infected when screening is legally required.

ALL of the following

Acid fast bacilli (AFB) smear/stain.
Culture and culture-based drug susceptibility testing of Mycobacteria spp.
Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M. tuberculosis, and M. avium complex.

ALL of the following

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

ALL of the following

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

For individuals with pleural effusion, pericardial effusion, or ascites and suspected TB infection, reimbursement may cover cell counts, protein, glucose, and lactate dehydrogenase (LDH) concentrations of cerebrospinal, pleural, peritoneal, pericardial, and other fluids.

Urine-based LAM testing may be reimbursable for HIV-infected individuals with CD4 cell counts ≤100 cells/µL who have signs and symptoms of tuberculosis.

Interferon gamma release assay (IGRA) is not reimbursable for individuals with active tuberculosis.

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

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

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

Reimbursement criteria (summary from update history)

Recent reimbursement updates and historical criteria entries (partial view in this document segment).

09/26/2025 update: Added to Reimbursement Information #2 — Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M. tuberculosis, and M. avium complex; replaced prior direct probe testing references (Hologic Amplified MTD) with NAAT and updated nomenclature to 'M. avium complex.' Codes added: 87564, 0574U. Codes removed: 87149, 87550, 87555, 87560.

10/30/2024 update: Document updated with literature review; Reimbursement Information unchanged; references revised.

02/01/2024 update: Document updated with literature review; Reimbursement Information revised for clarity; references revised.

11/01/2023 update: Combined prior #2 and #3 such that for all suspected TB infections the following may be reimbursable: AFB smear/stain; culture and culture-based drug susceptibility testing of Mycobacteria spp. Added molecular-based drug susceptibility testing for patients whose sputum is AFB smear positive or Hologic Amplified MTD positive when specified clinical criteria are met.

Procedure Codes and Coding Changes

Procedure codes listedmixed

81099
82945
83520
83615
84157
84311
86480
86481
87070
87077

1–10 of 29

1/3

Codes added and removed in latest updatemixed

87564	Newly added molecular diagnostic code (as listed in policy update)
0574U	Newly added molecular diagnostic code (as listed in policy update)
87149	Code removed per policy update
87550	Code removed per policy update
87555	Code removed per policy update
87560	Code removed per policy update

NAAT applicability

NAAT applicabilityQualitative nucleic acid amplification testing (NAAT) is listed as reimbursable for Mycobacteria spp., M. tuberculosis, and M. avium complex.

Replaced prior direct probe testsAddition of NAAT resulted in removal of prior direct probe testing entries as direct probe testing is no longer available.

Terminology updateReference to 'Hologic Amplified MTD' was replaced with 'NAAT' for clarity in reimbursement information.

Definitions and Terminology

Plan documents (governing coverage)

Governing plan documentsCertificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents govern coverage when conflicts arise.

Provider contractsIf a conflict arises between the policy and a provider contract, the provider contract will govern.

BCBSNM discretionBCBSNM may use reasonable discretion interpreting and applying this policy; BCBSNM has full and final discretionary authority as provided under applicable plan documents.

IGRA

IGRA definitionInterferon gamma release assay (IGRA) — a test to diagnose or screen for latent tuberculosis infection.

Reimbursable screening contextsIGRA may be reimbursable to diagnose or screen for latent TB in individuals at risk for Mycobacterium tuberculosis infection or when screening is legally required.

Provider Actions and Documentation Requirements

Documentation Required

Documentation and Claims Review

Providers are responsible for submitting accurate documentation of services performed. Claims are subject to review against plan documents, provider contracts, medical policies, clinical payment and coding policies, and claim-edit software logic. Upon request, providers must supply additional documentation to support medical necessity, coding, and reimbursement. Claims should be coded using HIPAA-approved code sets and industry-standard coding guidelines (e.g., UB, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG guidelines, CMS NCCI, CCI edits).

Submit claims using valid code combinations from HIPAA-approved code sets
Be prepared to provide supporting documentation upon request
Claims are subject to plan documents and provider contract terms

Billing Rule

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLAB027

Change TypeCoding updates and NAAT added to reimbursement guidance

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit accurate documentation upon request; claims are subject to plan documents, provider contracts, medical and coding policies, and code edit protocols.

SourceLink

On This Page

11/01/2022: New policy (initial effective date in this history).

Not reimbursable for active TBIGRA is not reimbursable for individuals with active tuberculosis.

LAM (urine LAM)

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

Reimbursement criteriaReimbursable for HIV‑infected individuals with CD4 cell counts ≤100 cells/µL who have signs and symptoms of tuberculosis.

Context of useIncluded in reimbursement information for suspected TB infections in the specific HIV/CD4 context.

Qualitative nucleic acid amplification testing for mycobacterial species (NAAT)

NAAT terminologyQualitative nucleic acid amplification testing (NAAT) — term used to describe molecular testing for mycobacterial species in reimbursement information.

Scope of NAATListed for Mycobacteria spp., M. tuberculosis, and M. avium complex for suspected TB infections.

Replacement of prior nameNAAT replaced references to direct probe testing methods (e.g., Hologic Amplified MTD) to clarify molecular testing usage.

Updated naming convention

Updated naming convention'M. avium intracellulare' updated to 'M. avium complex' to align with current naming conventions.

Applied in policy updatesChange applied in reimbursement information and policy update history entry dated 09/26/2025.

Affects NAAT scope languageThe updated name 'M. avium complex' is used alongside Mycobacteria spp. and M. tuberculosis in NAAT reimbursement language.

Reimbursement updates — NAAT added

Reimbursement information has been updated to add qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M. tuberculosis, and M. avium complex. NAAT operationally replaces prior direct probe tests; codes removed include 87149, 87550, 87555, and 87560. New/additional codes added include 87564 and 0574U. Language throughout the reimbursement section was revised to replace prior references (for example, replacing specific Hologic Amplified MTD wording with the broader term NAAT and updating organism names to current conventions).

Added: Qualitative NAAT for Mycobacteria spp., M. tuberculosis, and M. avium complex
Added codes: 87564, 0574U
Removed codes: 87149, 87550, 87555, 87560
Replaced references to direct probe testing and Hologic Amplified MTD with NAAT; updated organism naming to M. avium complex