β-Hemolytic Streptococcus Testing
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Coverage criteria for laboratory testing to detect β-hemolytic streptococcal infections (including Group A, B, C, G) across respiratory, blood, skin/soft tissue, and post-infectious serologic contexts for BlueCross BlueShield of Tennessee members.
No material clinical or coverage changes in this revision.
Coverage Criteria for β-Hemolytic Streptococcal Testing
Detection of streptococcal infection causing respiratory illness (pharyngitis)
Covered when ANY of the following are met:
Two-step algorithm recommended in pediatrics: if RADT is negative in children >3 years, obtain throat culture or NAAT for arbitration; consider collecting dual swab initially.
Blood culture testing
Covered when ANY of the following are met:
Follow guideline recommendations for inpatient vs outpatient indications; obtain cultures for hospitalized or clinically deteriorating patients.
Skin and soft tissue infections
Covered when ALL of the following are met:
Cultures are not routinely required for typical cellulitis or erysipelas unless clinical context (immunocompromise, severe disease, immersion injury, animal bite) warrants.
Serologic testing for ARF/PSGN
Covered when ANY of the following are met:
ASO typically peaks ~3–5 weeks after infection; ADB peaks later (6–8 weeks). Consider paired acute and convalescent titers.
Not covered / Does not meet coverage criteria
Specific exceptions exist for pediatric two-step testing and select clinical situations noted elsewhere in policy.
When diagnostic testing is medically indicated
Testing for GAS pharyngitis is recommended when clinical suspicion is high and generally not recommended when viral features are present or Centor/McIsaac score is <3.
ICSI consensus and CDC/AAP guidance recommend reserving testing for patients with higher pretest probability and intent to treat.
CDC and AAP recommend backup culture in this group; consider dual swab collection at initial visit.
Direct and amplified NAATs are more sensitive than antigen tests and negative NAAT results typically do not require arbitration.
Testing for GAS pharyngitis per ICSI
Covered when ALL of the following are met
This follows ICSI consensus guidance to reserve testing for patients likely to benefit from antibiotic therapy.
Cultures and blood testing for community-acquired pneumonia (CAP)
Guideline-based limitations for outpatient CAP testing
ATS/IDSA strong recommendation against routine outpatient testing.
PIDS–IDSA guidance supports selective culture in children who fail therapy or worsen.
Skin and soft tissue infection cultures (IDSA)
When to obtain Gram stain and culture from skin lesions
Consider cultures in immunocompromised patients, immersion injuries, animal bites, severe disease, or treatment failure.
Pharyngitis laboratory methods (ASM/IDSA guidance)
Acceptable diagnostic methods
Direct and amplified NAATs are more sensitive than antigen tests and typically do not require arbitration when negative.
Tiny colonies that react with C/G antigens may represent Streptococcus anginosus group rather than classical groups C/G.
Group B Streptococcus (GBS) screening in pregnancy
Screening and identification approaches
ASM endorses ACOG interval and recommends acceptable phenotypic/proteomic identification methods and NAAT from enrichment broth as acceptable approaches.
Report susceptibility to alternatives (vancomycin options described in guidelines).
Panel-style multiplex assays that screen for or identify multiple streptococcal strains (for example, Solana Strep Complete Assay or Lyra Direct Strep Assay) and identification of streptococcal organisms by MALDI‑TOF are specifically listed as tests that do not meet coverage criteria. These methods, as described in the policy, are excluded because the available published literature does not confirm they are required and beneficial for diagnosis and management of an individual’s illness.
Per AAP guidance cited in the policy, children with clear viral features (for example, rhinorrhea, cough, hoarseness, oral ulcers) should not be tested for Group A Streptococcus. The policy also notes that testing is generally not recommended for children younger than 3 years except in specific mitigating circumstances (for example, an affected symptomatic household contact).
The policy cites NICE guidance stating that rapid tests for Group A strep are not recommended for routine adoption for people with sore throat because they have limited additional impact on antimicrobial prescribing and patient outcomes compared with use of clinical scoring tools alone.
Procedure codes shown in policy documents are provided for general reference and may not be all‑inclusive. The absence of a code from this list does not imply coverage or noncoverage for a particular service; billing and coding must follow payer rules and contract terms.
Examples of contexts expressly identified as not meeting coverage include: bacterial culture from a throat swab when viral pharyngitis is suspected, ordering rapid antigen detection testing (RADT) as a follow‑up after culture or NAAT, using RADT as an asymptomatic screening method, and routine use of various enzymatic or multiplex panel assays and MALDI‑TOF identification. The policy states these uses are excluded due to insufficient evidence of clinical benefit.
The policy follows Centor/modified Centor guidance: testing for GAS pharyngitis is reserved for patients with higher pretest probability. Specifically, clinicians should generally not test when viral features (rhinorrhea, cough, oral ulcers, hoarseness) are present, and testing is advised when the modified Centor score is ≥ 3. Ordering tests for patients with modified Centor scores <3 or when viral features are present is discouraged and may not meet medical necessity.
Guideline recommendations referenced in the policy advise against routine microbiologic testing for outpatient community‑acquired pneumonia (CAP). The ATS/IDSA guidance recommends not obtaining sputum Gram stain and culture or blood cultures routinely for adults with CAP managed as outpatients; pediatric guidance (PIDS‑IDSA) similarly recommends against routine blood cultures in nontoxic, fully immunized children with outpatient CAP, reserving blood cultures for those who fail to improve or who clinically deteriorate.
Procedure and Diagnostic Codes
| not listed | Applicable CPT/HCPCS procedure codes section referenced but specific codes not present in this partial document. |
| 86060 | Antistreptolysin O; titer |
| 86063 | Antistreptolysin O; screen |
| 86215 | Deoxyribonuclease, antibody |
| 86317 | Immunoassay for infectious agent antibody, quantitative, not otherwise specified |
| 86318 | Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method (eg, reagent strip) |
| 87040 | Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) |
| 87070 | Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates |
| 87071 | Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool |
| 87077 | Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate |
| 87081 | Culture, presumptive, pathogenic organisms, screening only |
| 87430 | Infectious agent antigen detection by immunoassay technique; Streptococcus, group A |
| 87650 | Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique |
| 87651 | Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique |
| 87652 | Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification |
| 87797 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism |
| 87798 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism |
| 87070 | Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates. |
| 87071 | Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool. |
| 87077 | Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate. |
| 87081 | Culture, presumptive, pathogenic organisms, screening only. |
| 87430 | Infectious agent antigen detection by immunoassay technique; Streptococcus, group A. |
| 87650 | Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique. |
| 87651 | Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique. |
| 87652 | Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification. |
| 87797 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism. |
| 87798 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. |
Provider Actions, Billing, and Documentation Guidance
Procedure code reference
Procedure code reference: Use and billing for listed CPT/HCPCS codes should follow payer requirements. Procedure codes appearing in Medical Policy documents are provided for reference and may not be all‑inclusive; always verify applicable codes and billing guidance with BlueCross BlueShield of Tennessee.
Negative RADT follow-up risks
Negative RADT follow-up risks: Failure to perform indicated follow-up testing after a negative rapid antigen diagnostic test in children can lead to missed Group A Streptococcus (GAS) diagnoses, potential denial of coverage for subsequent claims, and gaps in care.
- In pediatric patients (>3 years) a negative RADT should be followed by throat culture or more sensitive NAAT when indicated; document the rationale if follow-up testing is not performed.
- RADT ordered as screening in asymptomatic patients, or used as a follow-up after culture/NAAT, may be denied.
Strep testing per ICSI/Centor guidance
Strep testing triage per ICSI/Centor guidance: Reserve testing for patients with a modified Centor/McIsaac score ≥3 and avoid testing when viral features are present (eg, cough, rhinorrhea, oral ulcers, hoarseness). Only test when there is intent to treat if positive.
- Do not test patients with modified Centor <3.
- Do not test patients with clear viral symptoms; document absence of viral features when testing is performed.
Blood/sputum culture recommendations for CAP
Blood and sputum culture recommendations for community‑acquired pneumonia (CAP): Do not obtain routine blood cultures or sputum Gram stain/culture in adults with outpatient, nonsevere CAP. Obtain cultures in patients who fail to improve, have progressive symptoms, or for hospitalized/complicated cases per ATS/IDSA and pediatric PIDS‑IDSA guidance.
- Adults with outpatient, nonsevere CAP: avoid routine blood and sputum cultures.
- Obtain blood cultures in adults/children who fail to demonstrate clinical improvement or who have progressive symptoms or suspected prosthetic joint infection; hospitalize and obtain cultures for moderate‑to‑severe or complicated CAP.
- In hospitalized children who can produce sputum, obtain sputum samples for culture and Gram stain as indicated.
Required clinical documentation
Required clinical documentation: Document clinical findings and decision rationale to support testing and claims. Include Centor criteria elements, presence/absence of viral features, symptom onset, and any communication plan for pending back‑up testing.
- Record modified Centor/McIsaac score and the specific criteria met (tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough, and age adjustments).
- Document clinical rationale for testing (symptoms, intention to treat) and whether arbitration/secondary testing was performed after a negative antigen test.
- For pediatric back‑up cultures: document the mechanism to notify families and to initiate antibiotics if the culture/NAAT becomes positive.
Clinical rationale and arbitration testing
Clinical rationale and arbitration testing: When a negative antigen test occurs in children and the RADT sensitivity is known or suspected to be <80%, perform secondary NAAT or culture to arbitrate possible false negatives; document the clinical rationale for arbitration testing and the outcome.
- Collect a dual swab at initial visit when possible so the second swab is available if needed; discard if primary antigen test is positive.
- Secondary testing is generally not required in adults, but do so in children when indicated by test sensitivity or clinical suspicion.
- Document symptom severity, Centor score, reason for arbitration testing, and results to support medical necessity.
Two-step testing for pediatric pharyngitis
Two‑step testing for pediatric pharyngitis: In children older than three years, perform RADT at point of care and follow a negative RADT with throat culture or sensitive NAAT as appropriate; collect a dual swab initially when feasible to facilitate this two‑step algorithm.
- If the direct antigen test is negative and test sensitivity <80%, obtain a second swab for NAAT or culture.
- Direct NAATs are more sensitive and may not require secondary arbitration; document the test used and reasoning.
Testing triage guidance
Testing triage guidance: Most acute pharyngitis is viral; avoid testing when viral symptoms are present. Reserve testing for patients with high pretest probability (modified Centor ≥3) or when clinical management would change based on results.
- Do not test children <3 years unless mitigating circumstances (eg, symptomatic household contact).
- Avoid testing as a screening tool in asymptomatic individuals.
Arbitration testing after negative antigen in children
Arbitration testing after negative antigen in children: When indicated, perform secondary NAAT or culture to resolve false negatives; ensure documentation of which secondary method was used and a plan to contact families if the secondary test is positive.
- If RADT sensitivity is <80% or clinical suspicion remains high, follow negative antigen with NAAT or culture.
- Have a documented process to inform the caregiver and start antibiotics if the backup result returns positive.
Background and Rationale
Group A Streptococcus (GAS; Streptococcus pyogenes) is a common cause of bacterial pharyngitis and can lead to post‑infectious complications. The policy highlights that antecedent GAS infection may be documented by rising serologic titers (for example, antistreptolysin O or anti‑DNase B), and that complications such as acute rheumatic fever (ARF) and post‑streptococcal glomerulonephritis (PSGN) can follow GAS pharyngitis. These clinical risks underline the targeted circumstances in which serologic and microbiologic testing meet coverage criteria.
Definitions and Test Method Glossary
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