CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO53

Hemolytic Streptococcus Testing Reimbursement

Defines Blue Cross Blue Shield Oklahoma reimbursement rules and limitations for laboratory testing to detect hemolytic streptococcal infections (throat, blood, skin) and rapid antigen/serologic or molecular tests; applies to providers billing BCBSOK plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHemolytic Streptococcus Testing Reimbursement

Policy CodePolicy CPCPLABO53

Change TypeNo material change

Effective DateNov 1, 2022

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims may be reviewed and require additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

Nov 1, 2022effective date

Newupdate history

Multiplenon-reimbursable

Reimbursement Criteria

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.

Reimbursement criteria for streptococcal testing

Reimbursable bacterial culture and blood culture testing scenarios and specified non‑reimbursable tests or uses.

ALL of the following

ANY of the following
- Patients with suspected bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea).
- Patients with a modified Centor score of 3 or greater.
- Symptomatic child or adolescent after a negative rapid antigen diagnostic test (RADT).

ALL of the following

ANY of the following
- Blood culture for patients who fail to demonstrate clinical improvement or who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy.
- Blood culture in cases of suspected prosthetic joint infection.
- Bacterial culture from skin swab or pus for suspected skin and/or soft tissue infections.

ALL of the following

ANY of the following
- Throat-swab bacterial culture for suspected viral pharyngitis is not reimbursable.
- Rapid antigen diagnostic testing (RADT) is not reimbursable when used as a screening method in an asymptomatic patient (except children under age 3 with a mitigating circumstance, such as a symptomatic household member).
- RADT is not reimbursable as a follow-up test to either a positive or negative bacterial culture, nor for suspected viral pharyngitis.
- Serological titer testing (e.g., ASO) is not reimbursable except when used for suspected acute rheumatic fever or poststreptococcal glomerulonephritis (PSGN).
- Simultaneous coding for both nucleic acid amplification and direct probe methods is not reimbursable.

ALL of the following

Not all requirements apply to every product; providers should review individual plan documents for coverage specifics.
For prenatal Group B Streptococcus screening, refer to policy CPCPLABO14.

ALL of the following

Centor criteria: tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough; each criterion is worth one point.

ALL of the following

Modified Centor score threshold for reimbursement consideration: 3 or greater.

Title metadata

Reimbursement criteria for streptococcal testing

Coding and Clinical Thresholds

General coding guidancemixed

No codes listed

Modified Centor score threshold

Modified Centor score threshold3 or greater

Use in reimbursement decisionsA modified Centor score of 3 or greater may make bacterial throat culture testing reimbursable for suspected streptococcal pharyngitis.

Applies to throat swab culturesReferenced specifically for bacterial culture testing from a throat swab for streptococcal infection.

Documentation & Claim Submission Requirements

Documentation Required

Documentation and claim submission requirements

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid code combinations from HIPAA‑approved code sets. Claims are subject to review under benefit coverage, provider contract language, medical and coding policies, and coding software logic; providers may be asked to submit additional documentation upon request.

Use valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10).
Code claims according to industry standard coding guidelines (UB, AMA CPT, CPT Assistant, NCCI, CMS guidance).
Be prepared to provide additional documentation if requested during claim review.

Clinical Definitions

Centor criteria

Tonsillar exudatesPresence of tonsillar exudates or tonsillar swelling (worth one point).

Tender anterior cervical lymphadenopathyTender anterior cervical lymph nodes (worth one point).

FeverHistory of fever (worth one point).

Absence of coughLack of cough (worth one point).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHemolytic Streptococcus Testing Reimbursement

Policy CodePolicy CPCPLABO53

Change TypeNo material change

Effective DateNov 1, 2022

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims may be reviewed and require additional documentation upon request.

SourceLink

On This Page

Panel tests that screen/identify multiple streptococcal strains (e.g., assays that detect group A, B, C/G, alpha- or V-hemolytic streptococci) are not reimbursable.

MALDI-TOF identification of streptococcus is not reimbursable.

Quantification of streptococcal strain by nucleic acid amplification (including PCR) is not reimbursable.

Hyaluronidase, streptokinase, or nicotinamide-adenine dinucleotide (NAD) activity assays and their corresponding immunoassays are not reimbursable (exceptions for suspected acute rheumatic fever or PSGN where noted).

Anti-streptolysin O immunoassay is not reimbursable except in cases of suspected acute rheumatic fever or PSGN.