CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO53

Hemolytic Streptococcus Testing

Defines Blue Cross Blue Shield of Texas reimbursement criteria for laboratory testing related to hemolytic streptococcal infections (throat, skin/soft tissue, serology) and limits on certain tests; applies to providers submitting claims to BCBSTX.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHemolytic Streptococcus Testing

Policy CodePolicy CPCPLABO53

Change TypeCode additions/removals and text revisions

Effective DateSep 26, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information: Deleted #2; revised now #5 by removing (c); revised now #9 by removing (b); added code 86581; removed code 87040.

Document updated with literature review.

1.0policy version

01/03/2026plan effective date

1 recordedrecent policy update

86581 addedprocedure code changes

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.

Streptococcal testing reimbursement criteria and exclusions

Reimbursement guidance for detection of streptococcal infection and related testing:

ANY of the following

Modified Centor criteria: reimbursement when the individual has a modified Centor score of 3 or greater (see Note 1).
When the individual is suspected of having bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea).
Following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent.

In cases of skin and/or soft tissue infections, bacterial culture testing for a streptococcal infection from a skin swab or from pus may be reimbursable.

ALL of the following

Serological titer testing.
Anti‑streptolysin O immunoassay.
Hyaluronidase activity or anti‑hyaluronidase immunoassay.
Streptokinase activity or anti‑streptokinase immunoassay.

ALL of the following

Bacterial culture from a throat swab is not reimbursable in cases of suspected viral pharyngitis.
RADT for streptococcal infection is not reimbursable except for asymptomatic children under age 3 with a mitigating circumstance (including a symptomatic family member); specifically RADT is not reimbursable as a follow‑up test after a bacterial culture or nucleic acid test, and not reimbursable as a screening method in an asymptomatic patient.
For all situations not described above, serological titer testing is not reimbursable.
For all situations not described above, testing with an anti‑streptolysin O immunoassay, a hyaluronidase activity or anti‑hyaluronidase immunoassay, or a streptokinase activity or anti‑streptokinase immunoassay is not reimbursable.
Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter is not reimbursable.

Overall coverage stance: covered with criteria (services described above may be reimbursable when criteria are met; many tests are excluded as noted).

Documentation and Claim Review Requirements

Documentation Required

Documentation and claim review — submit accurate documentation and provide additional records on request

Providers must submit accurate documentation of services and appropriate code combinations from HIPAA-approved code sets; upon request, the provider should submit any additional documentation to support the claim. Claims are subject to review against benefit coverage, provider contract language, medical and coding policies, clinical payment and coding policies, code edit protocols, and coding software logic — and may be denied or adjusted if documentation or coding do not support the services billed.

Ensure claims are coded according to industry-standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG rules, and CCI edits).
Be prepared to provide additional documentation upon request to substantiate medical necessity and the specific test ordered.
Understand that claim review includes plan documents, provider contract terms, medical policies, and automated code-edit protocols which can result in denial or adjustment.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHemolytic Streptococcus Testing

Policy CodePolicy CPCPLABO53

Change TypeCode additions/removals and text revisions

Effective DateSep 26, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request.

SourceLink

On This Page

OpenPayer

Hemolytic Streptococcus Testing

Streptococcal Testing — Coverage Criteria

Procedure Codes and Changes

Documentation and Claim Review Requirements

Key Definitions (Centor Criteria)

86581	Added to policy code list (specific test code added)
87040	Removed from policy code list