CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO53

Hemolytic Streptococcus Testing

Defines Blue Cross Blue Shield of Oklahoma's reimbursement criteria for laboratory testing to detect streptococcal infections (group A, B, C/G and related serologies) and limitations on reimbursable tests; applies to providers submitting claims to BCBSOK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHemolytic Streptococcus Testing

Policy CodePolicy CPCPLABO53

Change TypeAdded codesrevised exclusionsadded serology guidance

Effective Date

Next Review Date

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request; claims are subject to code-edit protocols and plan/provider contract terms.

SourceLink

POLICY UPDATE CHANGES

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

Updated Reimbursement Information #6.a to include nucleic acid testing as a follow-up test exclusion.

Added reimbursable serological testing options for suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN).

10+procedure codes referenced in policy

≥10distinct reimbursement bullets and exclusions

2022–2025document revision timeline

4explicitly listed non-reimbursable test types

Reimbursement Criteria and Exclusions

Reimbursement criteria and exclusions for streptococcus testing

Tests for streptococcal infections may be reimbursable only in the specified clinical situations below; explicit exclusions and non-reimbursable test types are listed.

Reimbursement criteria and exclusions for streptococcus testing

Throat culture (bacterial) reimbursable when

Modified Centor score >= 3
Individual is suspected of having 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

Blood culture reimbursable when

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHemolytic Streptococcus Testing

Policy CodePolicy CPCPLABO53

Change TypeAdded codesrevised exclusionsadded serology guidance

Effective Date

Next Review Date

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request; claims are subject to code-edit protocols and plan/provider contract terms.

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.

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

Skin/soft tissue culture reimbursable when: Bacterial culture testing from a skin swab or from pus in cases of skin and/or soft tissue infections

Serological testing reimbursable for suspected ARF or PSGN

Serological titer testing
Anti-streptolysin O immunoassay
Hyaluronidase activity or anti-hyaluronidase immunoassay
Streptokinase activity or anti-streptokinase immunoassay

Exclusions: throat bacterial culture: Bacterial culture testing from a throat swab is not reimbursable in cases of suspected viral pharyngitis

Exclusions: RADT: RADT for streptococcal infection is not reimbursable in the following situations except for asymptomatic children <3 years with a mitigating circumstance: as a follow-up test after a bacterial culture or a nucleic acid test; as a screening method in an asymptomatic patient; for individuals with suspected viral pharyngitis

Exclusions: serological and specific immunoassays: Serological titer testing and the listed immunoassays (anti-streptolysin O, hyaluronidase activity/anti-hyaluronidase, streptokinase activity/anti-streptokinase) are not reimbursable except as described for suspected ARF/PSGN or other situations explicitly listed

Exclusions: probe/amplification redundancy: Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter is not reimbursable

Exclusions: tests not reimbursable in any situation: The following are not reimbursable in any situation: panel tests that screen multiple streptococcal strains (e.g., Solana Strep Complete, Lyra Direct Strep), MALDI-TOF identification of streptococcus, quantification of streptococcus strains using nucleic acid amplification (including PCR), and nicotinamide-adenine dinucleotide activity or related immunoassay

Note: Prenatal Group B Streptococcus screening is addressed under related policy CPCPLABO14

Procedure Codes and Coding Notes

Streptococcus-related lab procedure codesCPT

86060
86063
86215
86317
86318
86581
87040
87070
87071
87077

1–10 of 19

1/2

Code list comprehensiveness

Scope of code listThe policy lists specific CPT/CPT‑like procedure codes related to streptococcal testing but does not present an exhaustive code set for all related services.

Inclusion does not equal coverageInclusion of a code in the policy’s code list does not guarantee reimbursement; coverage is determined by the clinical criteria and exclusions in the policy and the member’s plan document.

Number of codes referencedThe policy references 19 procedure codes for streptococcus‑related laboratory testing (e.g., 86060, 87650, 87880).

Code systemCodes are presented as procedure codes (CPT/CPT‑like) in the policy coding section.

Need to verify with claim adjudicationProviders should verify individual claim adjudication and plan-specific coverage rules prior to billing, as related codes may be subject to edits or contract terms.

Documentation and Claim Review Requirements

Documentation Required

Documentation and Claim Review — Provider Responsibilities

Providers are responsible for submitting accurate documentation and complete claims. Submit claims using valid code combinations from HIPAA‑approved code sets and code appropriately per industry standard coding guidelines (including but not limited to: Uniform Billing Editor, AMA CPT, CPT Assistant, HCPCS, ICD‑10‑CM/PCS, NDCs, DRG guidance, CMS NCCI Policy Manual and CCI edits). Claims are subject to review under plan benefit terms, provider contract language, medical policies, Clinical Payment and Coding Policies, and coding-software logic. Upon request, providers should furnish additional documentation to support the claim; failure to provide requested documentation may result in claim denial or reprocessing.

Submit claims with complete, accurate documentation and valid HIPAA-approved codes
Follow applicable coding guidelines (CPT, HCPCS, ICD-10, NDC, DRG, NCCI/CCI)
Claims may be reviewed and adjusted per benefit terms, contracts, policies, and edit logic
Provide additional documentation promptly when requested to avoid denial or delay

Clinical Definitions and Scoring

Modified Centor criteria (definition)

Criteria componentsTonsillar exudates; tender anterior cervical lymphadenopathy; fever; absence of cough.

ScoringEach of the four criteria is worth 1 point (modified Centor scoring).

Use in reimbursementA modified Centor score of 3 or greater is a stated condition under which bacterial throat culture testing may be reimbursable.

Reference noteCentor criteria definition appears as Note 2 in the Reimbursement Information section of the policy.