Currentblue cross blue shield - tennesseePolicy N/A

Identification of Microorganisms Using Nucleic Acid Probes

Defines coverage and reimbursement criteria for nucleic acid probe-based identification (direct probe, amplified probe, quantification) of individual microorganisms for BlueCross BlueShield Tennessee members; affects ordering providers and laboratories submitting claims for these CPT-coded tests.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyIdentification of Microorganisms Using Nucleic Acid Probes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDo not order multiple probe/quantification tests for the same organism in a single encounter; simultaneous ordering may be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40+CPT/HCPCS procedure codes listed in policy document

MCC / DNMCCCoverage designations in organism table

2Simultaneous ordering policy outcomes

Coverage Criteria

Covered when ALL of the following are met

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Organism/code-level coverage: Coverage status for each organism and technique is indicated by 'MCC' (meets coverage criteria) or 'DNMCC' (does not meet coverage criteria) in the policy table; providers must refer to the table for the specific CPT code.

See Table entries in policy chunks for per-organism determinations (examples: Bartonella amplified probe 87471 = MCC; Bartonella quantification 87472 = DNMCC; non-vaginal Candida 87481/87482 = DNMCC; cytomegalovirus 87495/87496/87497 = MCC).

Single-encounter ordering restriction: 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.

This is an absolute simultaneous-ordering exclusion and may result in denial.

Simultaneous ordering of any combination of direct probe, amplified probe, and/or quantification for the same organism in a single encounter is explicitly excluded and does not meet coverage criteria. Providers should not submit multiple techniques for the same organism at the same visit, as such simultaneous orders are subject to denial.

The policy table lists specific organism/technique combinations designated DNMCC (does not meet coverage criteria). Examples from the table include: non-vaginal Candida species with direct probe (87480), amplified probe (87481), and quantification (87482); Hepatitis G with direct (87525), amplified (87526), and quantification (87527); and Herpes virus-6 with direct (87531) and amplified (87532) (see policy table for the complete set of examples).

Covered Indications

Organism-specific detection when technique/code is designated 'MCC' in policy table

Organism-specific detection using nucleic acid probes when the technique/code is designated 'MCC' in the policy table:

Per-organism/code determinations (examples): Refer to the policy table for the organism and technique-specific CPT code designation; coverage is limited to those organism/technique combinations marked 'MCC'.

Examples from the table: Chlamydia pneumoniae amplified probe 87486 = MCC; Clostridium difficile amplified probe 87493 = MCC; Enterovirus amplified probe 87498 = MCC; Legionella amplified probe 87541 = MCC; Mycoplasma pneumoniae amplified probe 87581 = MCC; Respiratory syncytial virus amplified probe 87634 = MCC; Staphylococcus aureus amplified probe 87640 and MRSA amplified probe 87641 = MCC.

Exclusions within organism-level list: Organism/technique combinations listed as 'DNMCC' in the policy table are not covered and do not meet coverage criteria.

Examples from the table: Hepatitis G (87525/87526/87527) = DNMCC; Herpes virus-6 direct/amplified 87531/87532 = DNMCC (quantification 87533 = MCC); Non-vaginal Candida amplified/quantification 87481/87482 = DNMCC; Bartonella quantification 87472 = DNMCC.

Coding

Listed CPT Codes (part 1)CPT

87471	Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique.
87472	Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, quantification.
87480	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique.
87481	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique.
87482	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification.
87485	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique.
87486	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique.
87487	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification.
87493	Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique.
87495	Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique.

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Listed CPT Codes (part 2)CPT

87525	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, direct probe technique.
87526	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, amplified probe technique.
87527	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, quantification.
87531	Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique.
87532	Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique.
87533	Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, quantification.
87540	Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, direct probe technique.
87541	Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique.
87542	Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, quantification.
87580	Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique.

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Provider Actions & Billing

Note

Code-specific coverage designations

The coverage status for each listed CPT code (direct probe, amplified probe, quantification) is specified in the policy code table and summarized in the policy's indications section. In that table, MCC indicates the test meets coverage criteria and DNMCC indicates the test does not meet coverage criteria.

Examples: 87471 (Bartonella amplified probe) = MCC; 87472 (Bartonella quantification) = DNMCC; 87486 (Chlamydia pneumoniae amplified probe) = MCC; 87487 (Chlamydia pneumoniae quantification) = DNMCC; 87496/87497 (CMV amplified probe/quantification) = MCC.

Billing Rule

Prohibition on simultaneous ordering

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. Do not bill multiple methods for the same organism on the same encounter; claims may be denied if submitted together.

Applies to direct probe, amplified probe, and quantification CPT codes for the same organism.
If multiple techniques are clinically indicated on separate occasions, document the clinical rationale and timing.

Documentation Required

Benefit and regulatory dependencies

Coverage determinations depend on the member's benefit plan and applicable government rules. When there is a conflict between this policy and an applicable Medicare or Medicaid determination (LCD/NCD or state Medicaid rule), the government policy takes precedence. Verify member benefits and check current Medicare/Medicaid guidance before ordering or billing.

Confirm eligibility and benefit limitations at time of service.
Refer to CMS Medicare Coverage Database and applicable state Medicaid sites for up-to-date constraints.

Note

Provider operational guidance

Labs may use laboratory-developed tests (LDTs) that are performed in-house and regulated under CLIA as high-complexity tests; FDA clearance is not required for clinical use at this time. Ensure documentation describes the specific test method, validation, and clinical indication to support medical necessity and payment.

Document test type (direct probe/amplified probe/quantification), specimen source, and clinical indication.
Maintain validation and CLIA documentation for LDTs; include this information with prior authorization or audit requests as needed.

Ordering Requirements

Step Therapy

Ordering requirement — verify member benefits and applicable regulations

Before ordering, verify the member's benefit coverage and applicable Medicare/Medicaid rules because coverage determinations are dependent on those factors.

Confirm benefit eligibility and coverage for the specific CPT code at time of service.
When government policy (LCD/NCD/state Medicaid) conflicts with this policy, follow the government policy.

Definitions

Nucleic acid probe techniques (definitions)

Amplified probe techniqueProbe-based nucleic acid detection in which target sequences are amplified (eg, PCR) prior to probe hybridization for identification.

Direct probe techniqueProbe-based nucleic acid detection in which labeled probes hybridize directly to target DNA/RNA without prior amplification.

QuantificationMeasurement of nucleic acid target load (eg, viral/bacterial quantity) reported as a quantitative result rather than qualitative detection.

Background

Nucleic acid hybridization technologies identify microorganisms by exploiting complementary binding between nucleic acid strands. Common methods include direct probe assays (hybridization of a labeled probe to target DNA/RNA), amplified probe techniques such as PCR that increase target signal prior to detection, and quantification assays that measure nucleic acid load. Many organism-specific probes exist and may be combined in panels, but this policy addresses coverage for individual probe-based tests. Laboratory-developed tests must be validated and are regulated under CLIA as high-complexity testing.

Frequency Limits

Frequency limits and related ordering constraints

Simultaneous-ordering restrictionSimultaneous ordering of direct probe, amplified probe, and/or quantification for the same organism in a single encounter does not meet coverage criteria and may be denied.

Frequency limits specifiedNo specific repeat-interval frequency limits are listed in this policy document (procedure codes are provided for reference only).

Benefit verificationCoverage and any applicable limits depend on the member's benefit at time of request; providers should verify benefits prior to ordering.