CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB053

β-Hemolytic Streptococcus Testing (laboratory reimbursement criteria)

Reimbursement and coding criteria for laboratory testing to detect β-hemolytic streptococcal infections for BCBSOK products; affects providers submitting claims to Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policyβ-Hemolytic Streptococcus Testing (laboratory reimbursement criteria)

Policy CodePolicy CPCPLAB053

Change TypeClarification — no material coverage changes

Effective DateNovember 1, 2023

Next Review Date

Key ActionSubmit accurate documentation with claims; provider may be asked to supply additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information revised for clarity only; no new information added.

New policy

1.0policy version

2023-11-01plan effective date

2023-07-05committee approval

19reference chunks

2update entries

Coverage and Reimbursement Criteria

inv-01: Reimbursement criteria and exclusions for streptococcal testing

Tests reimbursable only when specific clinical indications are met; several tests and scenarios are explicitly not reimbursable.

Throat bacterial culture reimbursable when any of the following are met:

Modified Centor score ≥3 (see Note)
Suspected bacterial pharyngitis in the absence of viral features (including cough, oral ulcers, rhinorrhea)
Following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent

Blood culture reimbursable when any of the following are met:

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

Skin/soft tissue culture reimbursable: In cases of skin and/or soft tissue infection, bacterial culture testing from a skin swab or from pus may be reimbursable.

Throat culture not reimbursable: In cases of suspected viral pharyngitis, bacterial culture testing for streptococci from a throat swab is not reimbursable.

RADT limitations (not reimbursable): Except for asymptomatic children under age three with a mitigating circumstance (including a symptomatic family member), RADT is not reimbursable as a follow-up to culture (positive or negative), as screening in an asymptomatic patient, or in suspected viral pharyngitis.

Serologic titer testing limits: Except in cases of suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), serological titer testing is not reimbursable.

Simultaneous testing exclusion: Simultaneous coding for BOTH amplification and direct probes is not reimbursable.

Specific tests not reimbursable: Panel tests that detect multiple streptococcal strains, MALDI-TOF identification, anti-streptolysin O immunoassay (except for suspected ARF or PSGN), quantification by nucleic acid amplification (including PCR), hyaluronidase/streptokinase/nicotinamide-adenine dinucleotide activity assays (except for suspected ARF or PSGN) are not reimbursable.

inv-02: Coverage and reimbursement notes 6 policy status and revision history

Policy status and revision history note reimbursement information was clarified without adding new coverage rules.

Reimbursement information revised for clarity only; no new information added (document updated with literature review 7/5/2023).

Procedure Codes and Method References

Listed procedure codes (not exhaustive)CPT

86060
86063
86215
86317
86318
87040
87070
87071
87077
87081

1–10 of 18

1/2

References for diagnostic and laboratory methodsmixed

No codes listed

Modified Centor score threshold

Modified Centor score thresholdThroat swab bacterial culture may be reimbursable when the individual has a modified Centor score of ≥3.

Context for useApplies to detection of streptococcal infection causing respiratory illness (throat swab cultures).

Reference noteSee Note 2 for criteria components (tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough).

Documentation, Clinical Criteria, and Billing Actions

Documentation Required

Documentation and claims review

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and appropriate coding per industry standards (UB, AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI, etc.). Claims are subject to review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit additional documentation to support medical necessity and coding.

Submit accurate documentation upon request
Use HIPAA-approved code sets and industry standard coding guidelines
Claims may be denied or adjusted if unsupported by documentation

Prior Authorization

Prior-authorization-like clinical criteria for reimbursable tests

Clinical Definitions and Criteria

Modified Centor criteria

Modified Centor criteria (components)Tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough — each criterion is worth one point.

Scoring applicationUsed to determine reimbursement eligibility for throat swab bacterial culture when score is ≥3.

Clinical roleHelps distinguish suspected bacterial pharyngitis from viral features (absence of cough is a component).

References

Key guideline referencesShulman ST et al., Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis (IDSA, 2012) and ICSI Diagnosis and Treatment of Respiratory Illness (2017).

Diagnostic/lab method studies

Certain tests for suspected streptococcal infection are conditionally reimbursable only when clinical criteria are met. Providers should verify and document that the applicable clinical criteria are present prior to billing. Examples of reimbursable situations include throat culture when modified Centor score ≥ 3, throat culture when bacterial pharyngitis is suspected without viral features, and throat culture following a negative RADT in a symptomatic child/adolescent. Blood cultures are reimbursable when patients fail to improve or deteriorate after antibiotics or when prosthetic joint infection is suspected. Skin/soft tissue cultures are reimbursable for suspected streptococcal skin or soft tissue infections. Serologic titer testing is generally not reimbursable except for suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN). The simultaneous coding for both amplification and direct probe methods is not reimbursable. RADT and other tests have specific non-reimbursable uses (see items).