CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB063

Identification of Microorganisms Using Nucleic Acid Probes

Defines BCBS Oklahoma reimbursement stance and criteria for nucleic acid probe and amplification-based identification and quantification of microorganisms for laboratory testing; applies to providers submitting claims to BCBSOK for these services.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyIdentification of Microorganisms Using Nucleic Acid Probes

Policy CodePolicy CPCPLAB063

Change TypeNo material change

Effective DateNov 1, 2022

Next Review Date

Key ActionProviders must submit accurate documentation and code claims using HIPAA‑approved code sets and may be asked to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

Nov 1, 2022plan effective date

~40procedure codes referenced

Table 1reimbursement details

Reimbursement Criteria and Exceptions

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Reimbursement criteria and exceptions

Table 1 lists microorganisms with associated CPT codes and reimbursement status (MBR = may be reimbursable; INR = not reimbursable). Additional narrative identifies organisms for which PCR testing may be reimbursable despite lacking specific CPT codes, with clinical-context limitations.

Table-based mapping of microorganisms to CPT codes with reimbursement status as listed in Table 1; examples include: Bartonella henselae or quintana — 87471 (MBR), 87472 (INR); Candida species — 87480 (MBR) for vaginitis and 87480 (INR) for other situations, 87481 (INR), 87482 (INR); Chlamydia pneumoniae — 87485 (MBR), 87486 (MBR), 87487 (INR); Clostridium difficile — 87493 (MBR); Cytomegalovirus — 87495 (MBR), 87496 (MBR), 87497 (MBR); Enterovirus — 87498 (MBR); Hepatitis B — 87516 (MBR), 87517 (MBR); Herpes-virus-6 — 87531 (MBR), 87532 (INR), 87533 (MBR); Legionella pneumophila — 87540 (MBR), 87541 (MBR), 87542 (INR); Mycoplasma pneumoniae — 87580 (MBR), 87581 (MBR), 87582 (INR); Mycoplasma genitalium — 87563 (MBR); Respiratory syncytial virus — 87634 (MBR); Staphylococcus aureus — 87640 (MBR); Staphylococcus aureus, methicillin resistant — 87641 (MBR).

Quantification coding rule: The technique for quantification includes both amplification and direct probes; therefore, simultaneous coding for both amplification and direct probes is not reimbursable.

Clinical-utility exceptions: PCR testing for microorganisms that do not have specific CPT codes may be reimbursable when used for specific clinical indications. Selected examples enumerated in the policy include Actinomyces (identification in tissue), Adenovirus (adenovirus myocarditis or infection in immunocompromised hosts), Bacillus anthracis, BK polyomavirus (in transplant recipients on immunosuppression), Bordetella pertussis/B. parapertussis (whooping cough), Brucella spp. (with compatible exposure and symptoms), Burkholderia species, Chancroid (Haemophilus ducreyi) for genital ulcer disease, Coxiella burnetii (confirmation of acute Q fever), Ebola, epidemic typhus (Rickettsia prowazekii), Epstein–Barr virus for post‑transplant lymphoproliferative disorder or lymphoma evaluation, Francisella tularensis, Hantavirus, hemorrhagic fever viruses of Bunyaviridae family, Hepatitis D and E (for confirmation/definitive diagnosis with supporting serology), HTLV‑I/II in CSF when indicated, human metapneumovirus, JC polyomavirus (in specified immunocompromised populations), Leishmaniasis, Measles, Mumps, Neisseria meningitidis (when antibiotics were started before cultures), Parvovirus (chronic infection in immunocompromised persons), Psittacosis (Chlamydophila psittaci), Rubella, Toxoplasma gondii (immunocompromised or congenital), Varicella‑Zoster, Whipple's disease (Tropheryma whipplei) in tissue, and Yersinia pestis.

Procedure Codes and Coding Rules

Procedure codes referenced in policyCPT

87471	87471
87472	87472
87480	87480
87481	87481
87482	87482
87485	87485
87486	87486
87487	87487
87493	87493
87495	87495

1–10 of 35

1/4

Procedure codes referenced in policy (excerpted in brief)CPT

87471	Nucleic acid probe; Bartonella henselae or quintana, direct probe (example from table)
87472	Amplified probe; Bartonella henselae or quintana (example from table)
87480	Candida species direct probe (vaginitis reimbursable; other situations not reimbursable per table)
87516	Hepatitis B amplified probe (listed MBR)
87634	Respiratory syncytial virus amplified probe (listed MBR)
87640	Staphylococcus aureus amplified probe (listed MBR)

Quantification coding rule (inv-03)

Rule summaryQuantification includes both amplification and direct probes; simultaneous coding for both amplification and direct probes is not reimbursable.

Applies toQuantification procedures for nucleic acid testing (amplified probe and direct probe methods)

Billing implicationDo not report separate amplification and direct probe codes together for the same quantification service; only the appropriate quantification code should be billed.

Reference locationPolicy Reimbursement Information, section noting technique for quantification and simultaneous coding restriction.

Documentation and Claim Submission

Documentation Required

Documentation and claim submission — submit accurate, HIPAA‑approved coded claims and provide documentation on request

Providers are responsible for submitting accurate documentation of services performed and must submit claims using valid code combinations from HIPAA‑approved code sets. Claims are subject to code edit protocols and claim review against plan documents, provider contracts, medical policies, and coding software logic; BCBSOK may request additional documentation upon review. If a conflict exists between this policy and a plan document or provider contract, the plan document or provider contract governs, respectively.

Submit claims using valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10, NDC).
Ensure coding follows industry standard guidelines (UB Editor, AMA CPT, CPT Assistant, CMS NCCI/CCI edits).
Provide additional documentation upon BCBSOK request to support medical necessity and coding.
Be aware plan documents or provider contracts govern if they conflict with this policy.

Reimbursement Status Definitions

May be reimbursable — MBR (inv-05)

TermMBR (May be reimbursable)

DefinitionIndicates that the test may be reimbursable as listed in Table 1 when submitted with appropriate documentation and clinical indication.

Examples from Table 1Bartonella henselae/quintana 87471 (MBR); Chlamydia pneumoniae 87485/87486 (MBR); Cytomegalovirus 87495-87497 (MBR).

Action for providersSubmit claims with supporting clinical documentation to demonstrate medical necessity per plan requirements.

Not reimbursable — INR (inv-06)

TermINR (Not reimbursable)

DefinitionIndicates that the test is not reimbursable as listed in Table 1.

Examples from Table 1Bartonella 87472 (INR); Candida species 87481/87482 (INR for most situations); Chlamydia pneumoniae 87487 (INR).

ImplicationDo not bill BCBSOK for CPT codes listed as INR; claims for these codes are expected to be denied absent a change in policy or exceptional prior authorization.