CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO27

Testing for Diagnosis of Active or Latent Tuberculosis

Defines BCBSNM lab reimbursement criteria for tests used to diagnose or screen for latent and active tuberculosis and related specimen testing; applies to providers submitting claims to Blue Cross and Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLABO27

Change TypeCode additions and reimbursement criteria clarifications

Effective DateNov 19, 2024

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional documentation upon claim review.

SourceLink

POLICY UPDATE CHANGES

Added new CPT code 87564 effective 01/01/2025.

Reimbursement Information items #2 and #3 were combined into a single statement covering AFB smear/stain and culture with susceptibility testing for suspected TB infections.

Molecular-based drug susceptibility testing reimbursement criteria for sputum AFB smear positive or Hologic Amplified MTD positive patients when certain risk criteria are met.

≥1new CPT code added (87564)

12numbered reimbursement rules

1policy version

TB Testing Coverage Criteria

Procedure Codes & Coding Notes

Procedure codes referencedCPT

87564	New CPT code added effective 01/01/2025 (referenced in update history)
87149	Listed code in policy code list
87150	Listed code in policy code list
87153	Listed code in policy code list
87181	Listed code in policy code list
87184	Listed code in policy code list
87185	Listed code in policy code list
87186	Listed code in policy code list
87187	Listed code in policy code list
87188	Listed code in policy code list

1–10 of 12

1/2

Repeat susceptibility testing timing

Repeat susceptibility testing timingMay be reimbursable when sputum cultures remain positive after 3 months of treatment or when there is bacteriological reversion from negative to positive.

ApplicabilityApplies to repeat culture-based drug susceptibility testing for Mycobacteria spp. when clinical criteria in the policy are met.

Examples of timing triggers

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLABO27

Change TypeCode additions and reimbursement criteria clarifications

Effective DateNov 19, 2024

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional documentation upon claim review.

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.

Documentation and Claims Review Requirements

Documentation Required

Documentation and Claims Review — Provider Responsibilities

Providers are responsible for submitting accurate documentation and claims. Claims must be coded using valid code combinations from HIPAA-approved code sets and in accordance with industry coding guidelines (for example, Uniform Billing, AMA CPT/CPT Assistant, HCPCS, ICD-10-CM/PCS, NCD/DRG guidance, CMS NCCI policy manual and edits). Claims are subject to code-edit protocols and may be reviewed for correct coding, benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and claim-processing software logic. Upon request, providers must furnish additional documentation to support the services billed.

Submit claims using HIPAA-approved code sets (CPT, HCPCS, ICD-10, etc.)
Follow industry coding guidance (Uniform Billing, AMA CPT/CPT Assistant, CMS NCCI, DRG rules)
Claims are subject to code-edit protocols and claim review for coverage, contract terms, and policy compliance
Providers may be requested to provide additional documentation upon claim review

Test Definitions & Reimbursement Notes

IGRA reimbursement note

IGRA reimbursement for latent TBIGRA may be reimbursable to diagnose or screen for latent tuberculosis infection in individuals at risk or when screening is required by law.

Not reimbursable for active TBFor individuals with active tuberculosis, interferon gamma release assay (IGRA) is not reimbursable.

Use contextIntended for screening/diagnosis of latent infection; coverage contingent on plan documents and member’s clinical situation.

Tests reimbursable for suspected TB infections

Reimbursable tests for suspected TBAcid fast bacilli (AFB) smear/stain and culture with culture-based drug susceptibility testing of Mycobacteria spp may be reimbursable for all suspected TB infections.

ScopeIncludes culture-based susceptibility testing used to guide anti-tubercular therapy when TB is suspected.

Related molecular testingDirect probe or amplified probe nucleic acid-based testing (including PCR) may also be reimbursable for M. tuberculosis, Mycobacteria spp, and M. avium intracellulare.

LAM urine test

Urine LAM reimbursement criteriaUrine-based detection of lipoarabinomannan (LAM) may be reimbursable in HIV-infected individuals with CD4 cell counts <100 cells/µL who have signs and symptoms of tuberculosis.

Target populationHIV-infected patients with CD4 <100 cells/µL and clinical signs/symptoms suggestive of TB.

PurposeIntended to aid diagnosis of TB in severely immunocompromised individuals where LAM performance is more clinically useful.