ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB059

Diagnosis of Vaginitis laboratory testing and reimbursement

This document governs BCBSOK reimbursement criteria for laboratory testing used to diagnose vaginitis and applies to providers submitting claims under Blue Cross Blue Shield - Oklahoma products.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnosis of Vaginitis laboratory testing and reimbursement

Policy CodePolicy CPCPLAB059

Change TypeRevised guidance (NAAT panel reimbursement permissive)

Effective DateMar 15, 2024

Next Review DateN/A

Key ActionSubmit accurate documentation and claims using valid HIPAA-approved code sets; provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Revised reimbursement guidance to state NAAT panel testing designed to detect more than one type of vaginitis (VVC, BV, and/or trichomoniasis) may be reimbursable.

Added clarifying language and examples for NAAT testing in reimbursement items #8 and #9.

Document updated with literature review and references revised/added.

Policy title changed from 'Diagnosis of Vaginitis Including Multi-target PCR Testing.'

13reimbursable/non-reimbursable items

24procedure codes listed

3NAAT panel examples

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Coverage Criteria for Vaginitis Testing

Coverage criteria for vaginitis testing

Reimbursement stance varies by test and clinical scenario; items below summarize which tests may or may not be reimbursable.

Covered when ALL of the following apply:

ALL of the following

ONE of
- pH testing, testing for the presence of amines, saline wet mount, hydrogen peroxide (KOH) wet mount and microscopic examination of vaginal fluids for individuals with symptoms of vaginitis.
- Direct probe DNA-based identification (e.g., BD Affirm™ VPIII) for Gardnerella, Trichomonas, and Candida for individuals with symptoms of vaginitis.
- Vaginal cultures for Candida species when individuals have clinical signs and symptoms of vaginitis but negative wet mount and normal pH test.
- Measurement of sialidase activity in vaginal fluid for diagnosis of bacterial vaginosis for individuals with symptoms of vaginitis.
- NAAT or PCR-based identification of Trichomonas vaginalis for individuals with symptoms of vaginitis (screening asymptomatic individuals is addressed separately).
- PCR-based identification of Candida to confirm diagnosis and identify non-albicans species for individuals with complicated vulvovaginal candidiasis.
- NAAT assays specific to BV and single or multitarget PCR testing for diagnosis of BV for individuals with symptoms of bacterial vaginosis (examples provided in policy).
- NAAT panel testing designed to detect more than one type of vaginitis (VVC, BV, and/or trichomoniasis) may be reimbursable for individuals with symptoms of vaginitis.

Not reimbursable when ALL of the following apply:

Screening of asymptomatic individuals, including asymptomatic pregnant individuals at average or high risk for preterm labor, for trichomoniasis and bacterial vaginosis is not reimbursable.
Rapid identification of Trichomonas by enzyme immunoassay is not reimbursable for individuals with symptoms of vaginitis.
Molecular-based panel testing for microorganisms involved in vaginal flora imbalance and/or infertility is not reimbursable.
All other tests for vaginitis not specifically listed as reimbursable above are not reimbursable.

NAAT panel reimbursement stance

Reimbursement for multi-target NAAT panels

NAAT panel testing designed to detect more than one type of vaginitis (VVC, BV, and/or trichomoniasis; e.g., BD MAX™ Vaginal Panel, NuSwab® VG, Xpert® Xpress MVP) may be reimbursable.

Policy revision note: Language revised 03/15/2024 to change prior statement that such NAAT panel testing was not reimbursable; current policy states these multi-target NAAT panels may be reimbursable. Providers should refer to plan documents and submit supporting clinical documentation as requested.

Procedure and Example Panel Coding

Procedure codes listed in policy (not all-inclusive)mixed

81513
81514
82120
83986
87070
87149
87150
87210
87480
87481

1–10 of 26

1/3

Example NAAT panelsmixed

No codes listed

Documentation, Claim Submission, and Provider Guidance

Documentation Required

Documentation, valid HIPAA codes, and claim review/appeal expectations

Providers must submit accurate documentation of services performed and file claims using valid code combinations from HIPAA‑approved code sets (for example CPT®, HCPCS, ICD-10-CM/PCS, NDC) and follow industry standard coding guidelines and edits. Claims are subject to code edit protocols and may be reviewed against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic; upon request providers are urged to submit any additional documentation for review or appeal.

Submit claims using valid HIPAA‑approved code sets (CPT®, HCPCS, ICD‑10, NDC, etc.).
Ensure coding follows industry standard guidelines (UB Editor, AMA CPT®, CMS NCCI/CCI edits).
Be prepared to provide additional documentation upon request during claim review or appeal.

Definitions and Supporting References

Plan documents (definition and precedence)

Included documentsCertificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Governing precedence (plan documents)If a conflict arises between this Clinical Payment and Coding Policy (CPCP) and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Governing precedence (provider contract)If a conflict arises between this CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services, the provider contract will govern.

BCBSOK discretionBCBSOK may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case and has discretionary authority as provided under applicable plan documents.

Provider responsibilitiesProviders are responsible for submission of accurate documentation and for submitting claims using valid HIPAA-approved code sets; claims may be subject to review and additional documentation may be requested.