CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO59

Diagnosis of Vaginitis - Laboratory Testing Reimbursement

This policy defines Blue Cross Blue Shield of Oklahoma reimbursement criteria for laboratory testing used to diagnose vaginitis (including BV, VVC, and Trichomonas) and identifies which tests may or may not be reimbursable; it affects providers submitting claims for those diagnostic services for BCBSOK members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnosis of Vaginitis - Laboratory Testing Reimbursement

Policy CodePolicy CPCPLABO59

Change TypeCodes addedNAAT panel language revised

Effective DateNov 19, 2024

Next Review DateN/A

Key ActionSubmit accurate documentation and code claims per standard coding guidelines; claims may be subject to review and additional documentation requests.

SourceLink

POLICY UPDATE CHANGES

Added new CPT code 81515 effective 01/01/2025.

Added new code 0505U.

Revised NAAT panel testing policy language so NAAT panels detecting more than one type of vaginitis may be reimbursable.

13+distinct reimbursement statements

14procedure codes listed

2recently added codes

01/15/2025

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Reimbursement Criteria and Exclusions

Reimbursement criteria and exclusions

Covered when the following nested criteria are met; also lists exclusions and operational notes.

Reimbursement for diagnostic testing of vaginitis is governed by the specific clinical indications and exclusions below; providers should review member plan documents because coverage may vary by product.

Symptomatic individuals

For individuals with symptoms of vaginitis, testing of pH, testing for the presence of amines, saline wet mount, KOH (hydrogen peroxide) wet mount and microscopic examination of vaginal fluids may be reimbursable.
For individuals with symptoms of vaginitis, direct probe DNA-based identification of Gardnerella, Trichomonas, and Candida (e.g., BD Affirm VPIII) may be reimbursable.
For individuals with clinical signs and symptoms of vaginitis but with negative findings on wet-mount preparations and a normal pH test, vaginal cultures for Candida species for the diagnosis of vulvovaginal candidiasis may be reimbursable.
For individuals with symptoms of vaginitis, measurement of sialidase activity in vaginal fluid for the diagnosis of bacterial vaginosis may be reimbursable.
For individuals with symptoms of vaginitis, nucleic acid amplification test (NAAT) or polymerase chain reaction (PCR)-based identification of Trichomonas vaginalis may be reimbursable.
For individuals with complicated vulvovaginal candidiasis (VVC), PCR-based identification of Candida to confirm clinical diagnosis and identify non-albicans species may be reimbursable.
For individuals with symptoms of bacterial vaginosis (BV), NAATs specific to BV (examples include Aptima BV, OneSwab BV Panel PCR with Lactobacillus profiling by qPCR, SureSwab Advanced BV, TMA) and single or multitarget PCR testing for diagnosis of BV may be reimbursable.

Risk‑factor based screening

For individuals with risk factors for Trichomonas (new or multiple partners; history of sexually transmitted infections, especially HIV; exchange of sex for payment; incarceration; or injection drug use), screening for Trichomonas may be reimbursable.

Panel NAAT guidance: NAAT panel testing designed to detect more than one type of vaginitis (VVC, BV, and/or trichomoniasis) may be reimbursable.

Exclusions (not reimbursable)

For asymptomatic individuals, including asymptomatic pregnant individuals at average or high risk for premature labor, screening for trichomoniasis and bacterial vaginosis is not reimbursable.
For individuals with symptoms of vaginitis, rapid identification of Trichomonas by enzyme immunoassay is not reimbursable.
Testing for microorganisms involved in vaginal flora imbalance and/or infertility using molecular‑based panel testing is not reimbursable.
All other tests for vaginitis not addressed above are not reimbursable.

Operational notes: Claims are subject to code edit protocols, claim review, provider contract language, and CPCP policies; providers must submit documentation and may be asked for additional information. Procedure code lists in the policy are not all‑encompassing and inclusion does not guarantee coverage; see Policy Update History for recent code additions (e.g., CPT 81515 and 0505U).

Procedure and Assay Codes

Procedure/assay codes listedmixed

81513
81514
81515
82120
83986
87070
87149
87150
87210
87480

1–10 of 16

1/2

Procedure/assay codes listed (duplicate group for system clarity)mixed

81513
81514
81515
82120
83986
87070
87149
87150
87210
87480

1–10 of 16

1/2

New code effective date

Codes addedCPT code 81515 and code 0505U were added to the policy update history as effective 01/01/2025.

Policy update entryPolicy Update History notes addition dated 11/19/2024 with Summary of Changes effective 01/15/2025 indicating the codes were added effective 01/01/2025.

Implementation date vs. summary dateSummary of Changes dated 01/15/2025 documents the effective date for the new codes as 01/01/2025.

Documentation and Claims Submission

Documentation Required

Documentation, coding and claim-review obligations

Providers must submit accurate documentation of services performed and ensure claims use valid code combinations from HIPAA-approved code sets, coded according to industry standard coding guidelines (for example, Uniform Billing Editor, AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, and CMS National Correct Coding Initiative guidance). Claims are subject to code edit protocols and claim review, including plan benefit terms, provider contract language, medical and clinical payment and coding policies, and coding software logic; providers may be asked to submit additional documentation upon request.

Submit claims using valid HIPAA-approved code sets and appropriate industry-standard coding guidelines (CPT, HCPCS, ICD-10, etc.).
Be prepared for claim review driven by code edit protocols, plan documents, provider contracts, medical policies, and coding software logic.
Provide additional documentation when requested to support medical necessity and code selection.

Terms and Test Categories

Lab management reimbursement criteria

Reimbursement scopeBCBSOK implements lab management reimbursement criteria for vaginitis diagnostics; plan documents govern coverage specifics and requirements may not apply to every product.

Symptomatic testingFor individuals with symptoms, pH testing, amine test, saline wet mount, KOH wet mount, and microscopic examination of vaginal fluids may be reimbursable.

Follow-up testingIf wet-mount is negative with normal pH and symptoms persist, vaginal culture for Candida species may be reimbursable to diagnose vulvovaginal candidiasis.

Screening exclusionsScreening for trichomoniasis and bacterial vaginosis in asymptomatic individuals (including pregnant persons at average/high risk for preterm labor) is not reimbursable.

Claims/documentationProviders must submit accurate documentation and claims; claims are subject to code edit protocols, claim review, provider contract language, and CPCP policies.