ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB053

β-Hemolytic Streptococcus Testing

Laboratory management reimbursement criteria for testing related to β-hemolytic streptococcal infections for Blue Cross and Blue Shield of Oklahoma members; specifies when various streptococcal tests are reimbursable or not and highlights that requirements may vary by product.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policyβ-Hemolytic Streptococcus Testing

Policy CodePolicy CPCPLAB053

Change TypeCoding additionreimbursement clarifications

Effective DateJanuary 15, 2025

Next Review Date

Key ActionBill new CPT code 86581 where applicable and submit accurate documentation upon request.

SourceLink

POLICY UPDATE CHANGES

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

Reimbursement Information updated to include nucleic acid testing as acceptable follow-up testing.

Testing reimbursable for suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN): serological titer testing, anti-streptolysin O immunoassay, hyaluronidase activity or anti-hyaluronidase immunoassay, streptokinase activity or anti-streptokinase immunoassay.

For all situations not described above, certain serologic assays (ASO, hyaluronidase, streptokinase) are not reimbursable.

2025-01-15policy effective date

1.0policy version

2024-11-19

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.

19procedure codes listed

01/01/2025new CPT effective

Coverage Criteria for β-Hemolytic Streptococcus Testing

Reimbursement criteria

Situations where testing for streptococcal infection may be reimbursable or is not reimbursable.

Covered when ALL of the following reimbursement rules are satisfied as described below:

Throat swab / respiratory testing

Throat swab bacterial culture may be reimbursable when any ONE of the following conditions is met:
ANY of the following
- Modified Centor criteria score of 3 or greater (See Note 2).
- 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.

RADT restrictions

RADT is not reimbursable except for asymptomatic children under age 3 with a mitigating circumstance (including a symptomatic family member).
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 a streptococcal infection.
RADT is not reimbursable as a screening method in an asymptomatic patient or for individuals with suspected viral pharyngitis.

Blood culture

Blood culture testing may be reimbursable when any ONE of the following is met:
ANY of the following
- Individual fails to demonstrate clinical improvement.
- Progressive symptoms or clinical deterioration after initiation of antibiotic therapy.
- Cases of suspected prosthetic joint infection.

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

Serologic testing for ARF/PSGN

For individuals with suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), the following may be reimbursable:
ANY of the following
- Serological titer testing.
- Anti-streptolysin O immunoassay.
- Hyaluronidase activity or anti-hyaluronidase immunoassay.
- Streptokinase activity or anti-streptokinase immunoassay.

Non-reimbursable general rules

Bacterial culture testing from a throat swab is not reimbursable for suspected viral pharyngitis.
For all situations not described as reimbursable above, serological titer testing is not reimbursable.
For all situations not described above, testing with an anti-streptolysin O immunoassay, a hyaluronidase activity or anti-hyaluronidase immunoassay, or a streptokinase activity or anti-streptokinase immunoassay is not reimbursable.
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 (e.g., Solana Strep Complete, Lyra Direct Strep Assay), MALDI-TOF identification of streptococcus, quantification of any strain of streptococcus using nucleic acid amplification (including PCR), and nicotinamide-adenine dinucleotidase activity or related immunoassays.

Reimbursement criteria summary

Reimbursement criteria (high-level) based on policy update entries:

Policy updates effective 01/15/2025 include administrative coding and clinical clarifications as summarized below.

Follow-up testing

Nucleic acid testing or bacterial culture may serve as follow-up tests for individuals being evaluated for streptococcal infection (Updated to explicitly include nucleic acid testing as acceptable follow-up).

ARF/PSGN serology

For suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), serological titer testing and specified immunoassays (ASO, hyaluronidase, streptokinase or their anti-assays) may be reimbursable.

Other serology not reimbursed: Serologic assays (ASO, hyaluronidase, streptokinase) are not reimbursable for indications other than ARF or PSGN as described above.

Procedure and CPT Codes

Listed procedure codesmixed

86060
86063
86215
86317
86318
86581
87040
87070
87071
87077

1–10 of 19

1/2

Listed procedure codes (duplicate group for clarity)mixed

86060
86063
86215
86317
86318
86581
87040
87070
87071
87077

1–10 of 19

1/2

New/updated CPTCPT

86581

New CPT added effective 01/01/2025

Provider Responsibilities 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 follow industry-standard coding guidelines (e.g., AMA CPT, CMS NCCI edits, ICD-10-CM/PCS). Claims are subject to review against benefit terms, provider contract language, medical and clinical payment/coding policies, and coding software logic. Upon request, the provider should submit additional documentation to support the medical necessity and appropriateness of billed services.

Submit complete medical records and laboratory reports when requested during claims review.
Ensure coding aligns with the service performed and current coding manuals/guidance.

Billing Rule

Coding update / billing action

Definitions and Test Types

Centor criteria — components

Centor componentsTonsillar exudates; tender anterior cervical lymphadenopathy; fever; absence of cough — each criterion is worth one point.

Scoring useUsed to modify decision-making for throat swab bacterial culture reimbursement (e.g., modified Centor score ≥3 considered in criteria).

Source guidanceDefined in policy note referencing clinical criteria (Chow, 2023).

Nucleic acid testing — definition / policy reference

DefinitionNucleic acid testing referenced as an acceptable follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection.

Policy roleServes as an alternative or adjunct to bacterial culture when used for follow-up testing in the evaluation of streptococcal infection.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policyβ-Hemolytic Streptococcus Testing

Policy CodePolicy CPCPLAB053

Change TypeCoding additionreimbursement clarifications

Effective DateJanuary 15, 2025

Next Review Date

Key ActionBill new CPT code 86581 where applicable and submit accurate documentation upon request.

SourceLink

On This Page

Coding update: Administrative/coding addition: new CPT code 86581 added effective 01/01/2025; providers should bill accordingly when applicable.

Effective 01/01/2025, CPT code 86581 has been added. Providers should bill the appropriate CPT code for serologic testing consistent with the service performed and the effective date.

New CPT code: 86581 — effective 01/01/2025
Bill using CPT 86581 for the specific serologic procedure when it accurately reflects the service provided and the date of service is on or after 01/01/2025.

Billing Rule

Reimbursement conditions for serologic testing

Serologic testing (including anti-streptolysin O immunoassay, hyaluronidase activity or immunoassay, and streptokinase activity or immunoassay) is reimbursable only in specified clinical situations — for example, as part of the evaluation of suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), or as a follow-up test for individuals who have had a bacterial culture or nucleic acid test for streptococcal infection. For situations not described in the policy (i.e., routine or non-indicated testing), these serologic assays are not reimbursable. Providers should document the clinical indication clearly in the medical record and submit supporting documentation when requested during claims review.

Reimbursable examples: suspected ARF or PSGN; follow-up testing after positive bacterial culture or nucleic acid test for streptococcal infection.
Not reimbursable: routine screening or testing outside the specified clinical indications described above.
Documentation: include clinical signs/symptoms, relevant culture or nucleic acid test results, and rationale for serologic testing in the medical record.

Effective updatePolicy updated to explicitly include nucleic acid testing in follow-up testing language (document change recorded 11/19/2024).

Serologic assays (ASO, hyaluronidase, streptokinase) — definitions and policy scope

Reimbursable contextAnti-streptolysin O (ASO), hyaluronidase (or anti-hyaluronidase) and streptokinase (or anti-streptokinase) immunoassays may be reimbursable when used for suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN).

Non-reimbursable contextsFor all situations not described as reimbursable (i.e., other than suspected ARF or PSGN), these serologic assays are not reimbursable.

Assay types referencedAnti-streptolysin O immunoassay; hyaluronidase activity or anti-hyaluronidase immunoassay; streptokinase activity or anti-streptokinase immunoassay.