CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB057

Coronavirus Testing in the Outpatient Setting

This policy explains Blue Cross Blue Shield of Oklahoma's reimbursement stance and coding guidance for SARS-CoV-2 (COVID-19) testing in outpatient settings and which tests/indications are reimbursable or not; it applies to providers submitting claims to BCBS OK. Providers should also consult specific plan documents for product-specific requirements.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB057

Change TypeNo material changes

Effective DateNov 1, 2022

Next Review DateN/A

Key ActionSubmit accurate documentation upon request; claims are subject to review against plan documents and provider contracts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multipletest categories referenced

30+billing codes provided

<=5panel testing limit

Not reimbursedcollection codes

11/1/2022effective date

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Reimbursement and Coverage Criteria

Reimbursement criteria

Reimbursement criteria:

ALL of the following

Antibody testing for SARS-CoV-2 (COVID-19) provided under an FDA Emergency Use Authorization (EUA) during a public health emergency is not addressed by this policy.
Reimbursable targeted nucleic acid testing (e.g., RT-PCR)
- Individuals displaying signs and symptoms of possible COVID-19 infection (see NOTE 2).
- Asymptomatic individuals with known exposure to COVID-19.
- Asymptomatic individuals prior to undergoing immunosuppressive or aerosol-producing procedures.
Targeted nucleic acid testing (e.g., RT-PCR) may be reimbursable for detection of SARS coronavirus RNA in persons with signs or symptoms of SARS who have traveled to endemic areas or have been exposed to persons with SARS.
Targeted nucleic acid testing (e.g., RT-PCR) may be reimbursable for detection of MERS coronavirus RNA in persons with signs or symptoms of MERS who have traveled to endemic areas or have been exposed to persons with MERS.
Host antibody serology testing to support a diagnosis of Multisystem Inflammatory Syndrome in Children (MIS-C) or Multisystem Inflammatory Syndrome in Adults (MIS-A) or Post-Acute Sequelae of SARS-CoV-2 infection (PASC) may be reimbursable (see NOTES 3 & 4).
Use of an antigen-detecting diagnostic test in symptomatic individuals, including antigen rapid tests, may be reimbursable.
Multiplex PCR-based panel testing of up to 5 respiratory pathogens may be reimbursable for patients with signs and symptoms of a respiratory tract infection, evidenced by a compatible clinical syndrome including at least one of: temperature ≥102°F, pronounced dyspnea, tachypnea, or tachycardia.
Antigen panel testing of up to 5 antigens may be reimbursable for patients with signs and symptoms of a respiratory tract infection, evidenced by a compatible clinical syndrome including at least one of: temperature ≥102°F, pronounced dyspnea, tachypnea, or tachycardia.
Whole genome sequencing of paired specimens from distinct lineages (as defined in Nextstrain or GISAID) is not reimbursable to diagnose SARS-CoV-2 reinfection.
Antigen panel testing of 6 or more antigens is not reimbursable.
Multiplex PCR-based panel testing of 6 or more respiratory pathogens is not reimbursable.
Host antibody serology testing to diagnose an acute suspected COVID-19 (SARS-CoV-2) infection or any other human coronavirus infection is not reimbursable (except for MIS-C testing in children or MIS-A testing in adults).
Host antibody serology testing to determine immunity status for any human coronavirus is not reimbursable.
Neutralization antibody testing for SARS-CoV-2 is not reimbursable for any indications.
Testing for other endemic coronaviruses (e.g., 229E, NL63, OC43, HKU1) is not reimbursable.
Operational and billing rules
- AMA standard practice: do not include both the HCPCS and AMA code for the same procedure on the same date of service; only one code per date of service will be reimbursed.
- Specimen collection codes for coronavirus testing are considered incidental and will not be reimbursed.

Codes, Panels, and Coding Rules

Listed COVID-19 test codesmixedCovered

86318
86328
86408
86409
86413
86769
86790
87426
87428
87631

1–10 of 31

1/4

References supporting test types and regulatory statusmixed

No codes listed

inv-04: Maximum panel components reimbursed

Maximum components reimbursedMultiplex PCR or antigen panels of up to 5 respiratory pathogens/antigens may be reimbursable; panels of 6 or more targets are not reimbursable.

Clinical severity requirement (panels)Panel testing may be reimbursable for patients with signs and symptoms of a respiratory tract infection plus at least one severe feature (temperature ≥102°F, pronounced dyspnea, tachypnea, or tachycardia).

ScopeApplies to multiplex PCR-based respiratory pathogen panels and antigen panel testing used for respiratory infections.

Non-reimbursable examplesAntigen panel testing of 6 or more antigens and multiplex PCR-based panel testing of 6 or more respiratory pathogens are specifically not reimbursable.

Documentation, Claims, and Provider Responsibilities

Note

Interpretation and Authority

If a conflict arises between this Clinical Payment and Coding Policy and any member plan document, the plan document governs. If a conflict arises between this policy and a provider contract, the provider contract governs. Plan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. BCBS OK may use reasonable discretion when interpreting and applying this policy and has final discretionary authority to the extent provided under applicable plan documents.

Documentation Required

Provider Documentation and Claims Review

Providers are responsible for submitting accurate documentation and coding for services performed. Claims must use valid HIPAA-approved code sets and follow industry-standard coding guidelines (including UB, AMA CPT/CPT Assistant, HCPCS, ICD-10 CM/PCS, NDC, DRG, CMS NCCI guidance, and related edit protocols). 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 must submit additional documentation to support services billed; failure to provide adequate documentation may result in denial or recoupment.

Affected coding systems: CPT, HCPCS, ICD-10, NDC, DRG

Test Type Definitions and Testing Limits

inv-07: RT-PCR and rapid molecular tests

Test typeTargeted nucleic acid testing (e.g., RT-PCR and rapid molecular tests) for SARS-CoV-2 to detect viral RNA.

Reimbursable indications (symptomatic)Individuals displaying signs and symptoms of possible COVID-19 infection are eligible for reimbursable RT-PCR/rapid molecular testing.

Reimbursable indications (exposure/pre-procedure)Asymptomatic individuals with known exposure and asymptomatic individuals prior to immunosuppressive or aerosol-producing procedures may be reimbursable.

Other coronavirusesRT-PCR may be reimbursable for detection of SARS or MERS coronavirus RNA in persons with compatible signs/symptoms and relevant travel/exposure history.

inv-08: Serology tests

Permitted use

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB057

Change TypeNo material changes

Effective DateNov 1, 2022

Next Review DateN/A

Key ActionSubmit accurate documentation upon request; claims are subject to review against plan documents and provider contracts.

SourceLink

On This Page

Claims subject to code edit protocols and CCI/NCCI edits

Providers must submit additional documentation upon request

Host antibody serology testing to support diagnosis of MIS-C, MIS-A, or Post-Acute Sequelae of SARS-CoV-2 infection (PASC) may be reimbursable.

Not reimbursable for acute diagnosisSerology testing to diagnose an acute suspected COVID-19 infection or any other human coronavirus infection is not reimbursable (except MIS-C/MIS-A as noted).

Not reimbursable for immunity statusSerology testing to determine immunity status for any human coronavirus is not reimbursable.

Regulatory noteAntibody testing provided under FDA EUA during a public health emergency is not addressed by this policy.

inv-09: Antigen and multiplex panel testing limits

Panel target limitMultiplex PCR or antigen panels that include up to 5 targets (pathogens/antigens) may be reimbursable; panels with 6 or more targets are not reimbursable.

Clinical criteria for reimbursementReimbursable panels are intended for patients with respiratory tract infection signs and at least one severe clinical feature (e.g., temperature ≥102°F, pronounced dyspnea, tachypnea, tachycardia).

Explicit exclusionsAntigen panel testing of 6+ antigens and multiplex PCR-based panel testing of 6+ respiratory pathogens are explicitly not reimbursable.

inv-10: Additional definition entries

Definition: Targeted nucleic acid testingRT-PCR and rapid molecular tests detect SARS-CoV-2 viral RNA and are reimbursable for symptomatic individuals, asymptomatic individuals with known exposure, and certain pre-procedure asymptomatic testing.

Definition: Host antibody serologySerology testing may support diagnosis of MIS-C, MIS-A, or PASC; not for acute infection diagnosis or immunity determination.

Definition: Panel testing limitMultiplex PCR and antigen panels are limited to reimbursement for up to 5 targets; 6+ targets are excluded.

Reference guidancePolicy references FDA materials on EUA, multiplex assays, and diagnostic testing (see listed FDA references).