Testing for Diagnosis of Active or Latent Tuberculosis
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Clinical payment and coding policy describing reimbursement and coverage criteria for laboratory testing to diagnose active or latent tuberculosis for BCBSOK members; affects providers submitting claims for TB-related tests.
Reimbursement information revised for clarity based on literature review.
Added criteria for molecular-based drug susceptibility testing when sputum is AFB smear positive or Hologic Amplified MTD positive with specific risk factors.
Coverage Criteria for Tuberculosis Testing
Reimbursable Tests / Conditions
Covered when the following reimbursement criteria are met
Supports screening for latent TB
Includes nucleic acid-based testing for diagnosis
Specified high-risk criteria required
Monitoring treatment response
Diagnostic fluid studies for extrapulmonary TB
Targeted to severely immunocompromised patients
IGRA testing is not reimbursable for individuals with active tuberculosis. This policy explicitly excludes payment for interferon gamma release assays when the clinical context is active TB disease rather than screening or evaluation for latent infection. Providers should not bill IGRA codes for members with a documented diagnosis of active TB.
The policy lists specific testing modalities that are not reimbursable: (1) Quantitative nucleic acid testing for Mycobacterium spp., M. tuberculosis, and M. avium intracellulare; (2) Testing of adenosine deaminase (ADA) and interferon-gamma (IFN-γ) levels in cerebrospinal, pleural, peritoneal, pericardial, and other body fluids for extrapulmonary TB diagnosis; (3) Testing of serum protein biomarkers or biomarker panels for TB detection and diagnosis; and (4) Simultaneous ordering of a combination of direct probe, amplified probe, and/or quantification for the same organism in a single encounter. These services are excluded from payment under this policy.
Procedure Codes and Coding Guidance
Provider Responsibilities and Billing Actions
Product-specific coverage; verify plan benefits
Providers are urged to verify plan benefits and product-specific coverage before submitting claims. Not all lab management reimbursement criteria apply to every product; providers should review the member's plan documents (Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents) to confirm eligible coverage.
- Plan documents govern in the event of conflict between this CPCP and plan documents or provider contracts.
- Examples of plan documents: Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions.
Step therapy
None specified for this policy. If any step therapy requirements apply for a particular product, they will be listed in the applicable plan documents — providers should check the member's benefits prior to treatment.
Provider documentation responsibility
Providers are responsible for submission of accurate, complete documentation of services performed and must submit additional documentation upon request. Upon claim review or audit, BCBSOK may request medical records or other supporting documentation to substantiate services billed. Failure to provide requested documentation may result in denial or recoupment.
- Submit claims using valid code combinations from HIPAA-approved code sets.
- Be prepared to provide clinical notes, laboratory reports, and any other records that substantiate medical necessity and the services billed.
Coding and documentation compliance
Claims must be coded according to industry-standard coding guidelines and HIPAA-approved code sets. Claims are subject to coding edits, claim review, and coding software logic; claims that do not follow accepted coding conventions or that conflict with contract/benefit terms may be denied or adjusted.
- Follow coding resources such as UB Editor, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG guidelines, CMS NCCI policy manual, and CCI table edits.
- Claims may be denied if coding does not adhere to these code sets or industry coding guidelines.
Background and Clinical Context
Interferon gamma release assays (IGRAs) are intended for diagnosis or screening of latent tuberculosis infection, particularly in individuals at risk or when screening is required by law. By contrast, evaluation of suspected active TB relies on other modalities: acid-fast bacilli (AFB) smear/stain, mycobacterial culture with culture-based drug susceptibility testing (DST), and nucleic acid amplification tests (direct or amplified probe methods) to identify Mycobacteria species and M. tuberculosis complex. Molecular-based drug susceptibility testing may be indicated in high-risk situations (for example when sputum is AFB smear positive or Hologic Amplified MTD positive and specific risk factors are present). The policy therefore directs use of AFB smear, culture/DST, and nucleic acid testing for active disease while reserving IGRA for latent infection screening.
Definitions
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