Currentblue cross blue shield - tennesseePolicy N/A

Identification_Of_Microorganisms_Using_Nucleic_Acid_Probes_M2097

Defines coverage policy for nucleic acid probe-based identification (direct probe, amplified probe, quantification) of specific microorganisms, lists CPT procedure codes and coverage status (meets coverage criteria vs does not meet), and states limitations (simultaneous ordering). Applies to individual benefit coverage and references Medicare/Medicaid conflict precedence.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyIdentification_Of_Microorganisms_Using_Nucleic_Acid_Probes_M2097

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionVerify member benefit coverage prior to ordering tests.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy content.

~30CPT codes listed

ConditionalCoverage mix

1Explicit ordering prohibition

Coverage Summary

Defines coverage policy for nucleic acid probe-based identification (direct probe, amplified probe, quantification) of specific microorganisms, lists CPT procedure codes and coverage status (MEETS COVERAGE CRITERIA = MCC vs DOES NOT MEET COVERAGE CRITERIA = DNMCC), and states limitations including a prohibition on simultaneous ordering of multiple methods for the same organism. Policy applies to individual probe tests (panels are not reviewed here). For guidance on nucleic acid identification of Candida in vaginitis, refer to the separate vaginitis/Candida policy (AHS-M2057).

Medical Necessity / Coverage Criteria

General Coverage Rule by Test Type and Organism

Coverage status is determined per organism and per technique (direct probe, amplified probe, quantification) as listed below. 'MCC' = Meets coverage criteria; 'DNMCC' = Does not meet coverage criteria.

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Prohibition on Simultaneous Ordering

Limitation on ordering multiple test types for same organism in single encounter:

Simultaneous ordering of any combination of direct probe, amplified probe, and/or quantification for the same organism in a single encounter DOES NOT MEET COVERAGE CRITERIA.

If multiple methods are ordered for same organism in same encounter claim will not meet coverage criteria.

Definitions: MCC = Meets coverage criteria; DNMCC = Does not meet coverage criteria as used in the policy table.

Operational note: Policy reviews only individual probes; panels are not evaluated here.

Coding (CPT Procedure Codes)

Covered (MCC) CPT codes (amplified/direct/quantification as specified)CPTCovered

87471	Bartonella henselae and Bartonella quintana, amplified probe technique
87486	Chlamydia pneumoniae, amplified probe technique
87493	Clostridium difficile, toxin gene(s), amplified probe technique
87495	Cytomegalovirus, direct probe technique
87496	Cytomegalovirus, amplified probe technique
87497	Cytomegalovirus, quantification
87498	Enterovirus, amplified probe technique
87500	Enterococcus vancomycin resistance, amplified probe technique
87541	Legionella pneumophila, amplified probe technique
87540	Legionella pneumophila, direct probe technique

1–10 of 17

1/2

Not covered (DNMCC) CPT codesCPTNot Covered

87472	Bartonella henselae and Bartonella quintana, quantification
87480	Candida species, direct probe technique (non-vaginal)
87481	Candida species, amplified probe technique (non-vaginal)
87482	Candida species, quantification (non-vaginal)
87487	Chlamydia pneumoniae, quantification
87525	Hepatitis G, direct probe technique
87526	Hepatitis G, amplified probe technique
87527	Hepatitis G, quantification
87531	Herpes virus-6, direct probe technique
87532	Herpes virus-6, amplified probe technique

1–10 of 12

1/2

Procedure codes listed for reference (system note)CPT

87471	Infectious agent detection by nucleic acid; Bartonella henselae and Bartonella quintana, amplified probe technique
87472	Bartonella henselae and Bartonella quintana, quantification
87480	Candida species, direct probe technique
87481	Candida species, amplified probe technique
87482	Candida species, quantification
87485	Chlamydia pneumoniae, direct probe technique
87486	Chlamydia pneumoniae, amplified probe technique
87487	Chlamydia pneumoniae, quantification
87493	Clostridium difficile, amplified probe technique
87495	Cytomegalovirus, direct probe technique

1–10 of 30

1/3

Coverage status is determined per organism and per technique (direct probe, amplified probe, quantification) as listed in the policy table; the same organism may have different coverage status depending on the technique used. Many organisms have blank entries for Direct Probe or Quantification in the table, which are interpreted as not listed/coverage not indicated for those cells.

Provider Actions & Billing Rules

Documentation Required

Verify member benefit coverage

Application of coverage criteria depends on the individual's benefit coverage at the time of the request; providers must verify member benefits prior to ordering tests.

Billing Rule

Do not report multiple methods for same organism in same encounter

Simultaneous ordering of direct probe, amplified probe, and/or quantification for the same organism in a single encounter does not meet coverage criteria and should not be submitted together for the same encounter.

Prohibition: Ordering multiple methods for the same organism in one encounter is not covered.
Affected methods: direct probe, amplified probe, quantification

Background & Evidence

Nucleic acid hybridization technologies utilize complementary properties of DNA to anneal fragments from different sources and are used in techniques such as polymerase chain reaction (PCR) and fluorescent resonance energy transfer (FRET) to identify microorganisms.

This policy reviews only individual probe tests (not comprehensive panels). For nucleic acid testing of Candida in vaginitis, refer to the separate vaginitis/Candida policy (AHS-M2057).

Evidence sources cited in the policy include CDC guidance, FDA resources, IDSA/ASM guidance, the AAP Red Book, and multiple peer-reviewed publications.