Testing for Diagnosis of Active or Latent Tuberculosis
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Defines BCBSOK reimbursement and coding stance for laboratory tests to diagnose or screen for active and latent tuberculosis, including restrictions and conditions for reimbursement for providers billing BCBSOK.
Added codes 87182 and 87183.
Added codes 87564 and 0574U and removed codes 87149, 87550, 87555, 87560.
Qualitative NAAT for Mycobacteria spp., M. tuberculosis, and M. avium complex was added and direct probe testing was removed.
Coverage Criteria for TB Testing
TB testing coverage rules
Reimbursable tests and conditions
ALL of the following
ONE of
- IGRA may be reimbursable to diagnose or screen for latent TB in individuals at risk for Mycobacterium tuberculosis (Mtb) infection or when screening is legally required.
- For suspected TB infections, the following may be reimbursable: AFB smear/stain; culture and culture-based drug susceptibility testing of Mycobacteria spp.
- Direct probe or amplified probe nucleic acid-based testing, including PCR, may be reimbursable for Mycobacteria spp, M. tuberculosis, and M. avium intracellulare (note: policy history replaces vendor-specific terminology with NAAT).
ALL of the following
ONE of
- Prior treatment for tuberculosis.
- Born in or lived ≥1 year in a foreign country with at least moderate TB incidence (≥20 per 100,000) or with high primary MDR-TB prevalence (≥2%).
- Contact of an individual with multi-drug resistant (MDR) TB.
- HIV infection.
ALL of the following
ONE of
- 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, measurement of cell counts, protein, glucose and lactate dehydrogenase (LDH) concentrations of cerebrospinal, pleural, peritoneal, pericardial, and other fluids may be reimbursable.
Reimbursement criteria summary
Reimbursement information and clinical criteria (as summarized in policy history):
ALL of the following
- AFB smear/stain, culture, and culture-based drug susceptibility testing are listed as reimbursable for suspected TB infections.
- Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M. tuberculosis, and M. avium complex was added to reimbursable tests; direct probe testing was removed as it is no longer available and vendor-specific references (eg, Hologic Amplified MTD) were replaced with NAAT terminology.
- Molecular-based drug susceptibility testing may be reimbursable for AFB smear positive or NAAT positive patients when clinical risk factors are present (prior TB treatment; birth in or ≥1 year residence in country with moderate/high TB incidence; contact of an MDR-TB case; or HIV infection).
Procedure Codes and Coding Changes
Provider Responsibilities and Update Actions
Documentation and Claims Review — submit accurate documentation and respond to requests
Providers are responsible for submission of accurate documentation of services performed and must code claims using valid HIPAA-approved code sets and industry standard coding guidelines. Claims are subject to code edit protocols and may be reviewed against plan coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic; upon request, providers should submit any additional documentation to support the claim.
- Submit accurate documentation of services performed.
- Use valid code combinations from HIPAA-approved code sets and follow industry coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, UB, NDC, CMS NCCI/CCI, etc.).
- Be prepared for claim review against plan documents, provider contracts, medical/clinical payment and coding policies, and automated code edits.
- Provide additional documentation promptly upon request.
Coding update actions — use updated CPT/HCPCS/Lab codes
The policy history documents specific CPT/HCPCS/Lab code additions and removals; providers must use the updated codes when billing for TB-related tests per the policy update history.
Definitions and Test Descriptions
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