ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB053

β-Hemolytic Streptococcus Testing

Reimbursement and coding criteria for laboratory testing to detect β-hemolytic streptococcal infections, specifying when culture, RADT, blood cultures, serologies, and panels are reimbursable or excluded for BCBSOK; applies to providers submitting claims to BCBSOK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policyβ-Hemolytic Streptococcus Testing

Policy CodePolicy CPCPLAB053

Change TypeMaterial updates (code addition and reimbursement clarifications)

Effective DateNov 19, 2024

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and applicable HIPAA codes; do not bill for non-indicated tests outside listed indications.

SourceLink

POLICY UPDATE CHANGES

Added new CPT code 86581 effective 01/01/2025.

Reimbursement Information #6.a updated to include nucleic acid testing as an acceptable prior test for follow-up.

For suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), serological titer testing and specific immunoassays may be reimbursable.

Testing with anti-streptolysin O immunoassay, hyaluronidase assays, or streptokinase assays is not reimbursable except as described for ARF/PSGN.

1new CPT code added (86581)

3serologic tests reimbursable for ARF/PSGN

20procedure codes enumerated

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policyβ-Hemolytic Streptococcus Testing

Policy CodePolicy CPCPLAB053

Change TypeMaterial updates (code addition and reimbursement clarifications)

Effective DateNov 19, 2024

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and applicable HIPAA codes; do not bill for non-indicated tests outside listed indications.

SourceLink

On This Page

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Reimbursement and Coverage Criteria

Reimbursement criteria and exclusions

Tests for detection of streptococcal infection are reimbursable only under specified clinical indications; several tests and scenarios are expressly excluded from reimbursement.

ANY of the following

Modified Centor criteria score of 3 or greater (see note).
Suspected bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea).
Following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent.

ANY of the following

Individual fails to demonstrate clinical improvement.
Progressive symptoms or clinical deterioration after initiation of antibiotic therapy.
Suspected prosthetic joint infection.

Skin and/or soft tissue bacterial culture from a skin swab or from pus reimbursable for suspected streptococcal skin/soft tissue infections.

ANY of the following

Serological titer testing.
Anti-streptolysin O (ASO) immunoassay.
Hyaluronidase activity or anti-hyaluronidase immunoassay.
Streptokinase activity or anti-streptokinase immunoassay.

RADT is not reimbursable except in asymptomatic children under age three with a mitigating circumstance (including a symptomatic family member); RADT is not reimbursable as a follow-up test after a bacterial culture or nucleic acid test, as a screening method in an asymptomatic patient, or for suspected viral pharyngitis.

Serological titer testing and specific immunoassays (ASO, hyaluronidase, streptokinase) are not reimbursable for situations other than the ARF/PSGN exceptions described above.

Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter is not reimbursable.

The following tests are not reimbursable in any situation: panel tests that screen and identify multiple streptococcal strains (immunoassay or nucleic acid-based), MALDI-TOF identification of streptococcus, quantification of any streptococcal strain using nucleic acid amplification (including PCR), and nicotinamide-adenine dinucleotide activity or related immunoassays.

Reimbursement criteria (policy update history summary)

Summary of changes recorded in the Policy Update History that affect reimbursement criteria.

Added new CPT code 86581 effective 01/01/2025 (policy update entry).

Updated follow-up testing reimbursement to include individuals who have had either a bacterial culture test or a nucleic acid test for streptococcal infection (Reimbursement Information #6.a revised).

For suspected ARF or PSGN, reimbursable testing may include serological titer testing and the following immunoassays: anti-streptolysin O, hyaluronidase activity/anti-hyaluronidase, and streptokinase activity/anti-streptokinase (added in 03/01/2024 update).

Clarified that anti-streptolysin O immunoassay, hyaluronidase assays, and streptokinase assays are not reimbursable outside the described ARF/PSGN exceptions.

Procedure and CPT Codes

Procedure codes listed (not exhaustive)CPT

86060
86063
86215
86317
86318
86581
87040
87070
87071
87077

1–10 of 19

1/2

Relevant CPT additionsCPT

86581

New CPT code added effective 01/01/2025

Provider Documentation, Billing and Denial Risk

Documentation Required

Documentation and claim submission requirements

Providers are responsible for submitting accurate documentation and supporting medical records upon request to substantiate medical necessity for testing. Claims must use valid HIPAA code sets and adhere to industry-standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CCI edits, etc.). Claim submissions are subject to review against benefit coverage, provider contract terms, applicable medical and clinical payment/coding policies, and automated coding logic. Providers should retain documentation of clinical findings (e.g., Centor score, presence/absence of viral features, RADT results, prior culture or nucleic acid tests) when ordering streptococcal testing.

Use industry-standard code combinations from HIPAA-approved code sets when submitting claims.
Submit additional documentation upon request to support medical necessity (e.g., modified Centor criteria score, RADT results, clinical course).
Claims are subject to code edits and clinical review; inaccurate or unsupported claims may be denied.

Denial Risk

Key Definitions and Exceptions

inv-08: Modified Centor criteria — definition

DefinitionModified Centor criteria: one point each for tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough.

Scoring useThroat swab bacterial culture may be reimbursable when modified Centor score is 3 or greater.

Clinical contextApplied to detection of streptococcal respiratory infection to guide reimbursement for bacterial culture testing.

Related exclusionsIn suspected viral pharyngitis, bacterial throat culture for streptococci is not reimbursable.

inv-09: Reimbursable serologic testing exceptions

Reimbursable exceptionsFor suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), reimbursable tests may include serological titer testing and specific immunoassays (anti-streptolysin O, hyaluronidase activity/anti-hyaluronidase, streptokinase activity/anti-streptokinase).

Policy Update History

2024-11-19effective_date / code additionLatest

Added new CPT code 86581 effective 01/01/2025 (listed in Policy Update History as effective 11/19/2024 with summary noting the 01/01/2025 code addition).

2024-10-30content_update

Revised Reimbursement Information #6.a to include nucleic acid testing as an acceptable prior test for follow-up (now allows follow-up after bacterial culture or nucleic acid test); literature references updated.

2024-03-01

Billing Rule

Prior testing and reimbursement conditions

Follow-up or repeat testing reimbursement is limited. RADT is not reimbursable as a follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for streptococcal infection. Serological titer testing, anti‑streptolysin O immunoassay, hyaluronidase or anti‑hyaluronidase immunoassay, and streptokinase or anti‑streptokinase immunoassay are reimbursable only in specified clinical situations (e.g., suspected acute rheumatic fever or post‑streptococcal glomerulonephritis, or when criteria in Reimbursement Information are met); otherwise these serologies are not reimbursable. Note: CPT code 86581 was added effective 01/01/2025 — providers should use the new code where applicable beginning 01/01/2025 and check plan/product-specific coverage details.

RADT is not reimbursable as a follow-up after bacterial culture or nucleic acid testing.
Serological titer testing and specified immunoassays are reimbursable only for defined indications (e.g., suspected ARF or PSGN); otherwise not reimbursable.
New CPT code 86581 effective 01/01/2025 — use as applicable starting 01/01/2025 and verify reimbursement rules per product.