ModifiedBlue Cross Blue Shield - TexasPolicy CPCPLABOS7

Coronavirus Testing in the Outpatient Setting (Reimbursement)

Defines reimbursement criteria and coding guidance for outpatient SARS-CoV-2 diagnostic and serologic testing for Blue Cross and Blue Shield of Texas members; applies to providers submitting claims for covered services under BCBSTX plans.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLABOS7

Change TypeMultiple revisions and removals

Effective DateJul 25, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and coding; claims are subject to review and may require additional documentation.

SourceLink

POLICY UPDATE CHANGES

NAAT was added as an acceptable test option for MIS-A and MIS-C and wording was revised for clarity.

Frequency for a specified testing item was updated to once every 48 hours.

Coverage item 1c for asymptomatic individuals prior to undergoing immunosuppressive or aerosol-producing procedures was removed from reimbursement information.

Several codes (including 86318, 86790, 87428, 87631-87633, 87797, 87799, 0115U, 0202U, 0223U, 0225U, C9803) were removed from the policy's code list.

Multiple items related to whole genome sequencing and certain numbered items (#6, #7, #8, #10) were removed or delegated to another policy.

Literature review references were updated and references revised during the document update.

1.0policy version

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Reimbursement and Coverage Criteria

Reimbursement criteria

Reimbursement is conditional and limited to the following clinical scenarios and test types.

ALL of the following

ANY of the following
- ALL of the following
  - Diagnostic testing (including nucleic acid amplification/RT-PCR and antigen tests) may be reimbursable for individuals displaying signs or symptoms of possible COVID-19 infection (see NOTE 2).
- ALL of the following
  - Testing for asymptomatic individuals with known exposure to COVID-19 may be reimbursable, EXCEPT when the individual has had a previous COVID-19 infection within the last 90 days.
ALL of the following
- For individuals with signs or symptoms of SARS or MERS who have traveled to endemic areas or been exposed to persons with SARS or MERS, targeted nucleic acid testing (e.g., RT-PCR) may be reimbursable.
ALL of the following
- To support diagnosis of multisystem inflammatory syndrome in children (MIS-C), multisystem inflammatory syndrome in adults (MIS-A), or post-acute sequelae of SARS‑CoV‑2 infection (PASC), nucleic acid amplification testing and host serology testing may be reimbursable.
ALL of the following
- For symptomatic individuals, antigen-detecting diagnostic tests for SARS‑CoV‑2 (for example, antigen rapid tests) may be reimbursable once every 48 hours.once every 48 hours
ALL of the following
- ANY of the following
  - Host antibody serology testing is not reimbursable for situations not described in the reimbursable scenarios listed in this policy.
  - Neutralization antibody testing for SARS‑CoV‑2 is not reimbursable.
  - Testing for other endemic human coronaviruses (e.g., 229E, NL63, OC43, HKU1) is not reimbursable.

ALL of the following

Inclusion of a code in the policy's code list does not guarantee coverage or payment; claims are subject to code edit protocols, contract language, benefit terms, and clinical payment and coding policies. Providers should code per industry standards and may be asked to provide additional documentation.

Reimbursement criteria updates

Summary of reimbursement changes, reassignments, and operational impacts.

ALL of the following

Removed coverage item for asymptomatic individuals prior to immunosuppressive or aerosol‑producing procedures (item 1c removed).
NAAT (nucleic acid amplification testing) explicitly added as an acceptable test option for MIS‑A and MIS‑C (clarified in reimbursement item #4).
Updated antigen testing frequency: specified repeat testing frequency for the identified antigen test changed to once every 48 hours.once every 48 hours
Certain reimbursement items, whole genome sequencing items, and multiple codes were removed or reassigned to CPCPLABO4S Pathogen Panel Testing; several laboratory codes were deleted from the policy code list.

Procedure Codes and Coding Guidance

Procedure codes referencedmixed

86328	Antibody; immunoassay for infectious agent (generic) - listed in policy code list
86408	SARS-CoV-2 antibody, IgG
86409	SARS-CoV-2 antibody, IgM
86413	SARS-CoV-2 antibody, multiple isotypes/methods
86769	Antibody detection for other coronavirus (listed)
87426	Infectious agent antigen detection by immunoassay, SARS-CoV-2
87635	Infectious agent detection by nucleic acid (e.g., RT-PCR), SARS-CoV-2
87798	Unlisted infectious disease test (listed)
87811	Unlisted antigen/viral testing (listed)
0224U	Proprietary COVID-19 molecular/other lab code (listed)

1–10 of 14

1/2

Removed codesmixedNot Covered

86318	Deleted from policy code list
86790	Deleted from policy code list
87428	Deleted from policy code list
87631	Deleted from policy code list
87632	Deleted from policy code list
87633	Deleted from policy code list
87797	Deleted from policy code list
87799	Deleted from policy code list
0115U	Deleted from policy code list
0202U	Deleted from policy code list

1–10 of 13

1/2

Repeat testing frequency — operational rule (inv-05)

Repeat testing intervalOnce every 48 hours for the specified antigen testing item (updated policy rule).

ScopeApplies to the identified testing item described in Reimbursement Information #5 for symptomatic individuals.

Effective date of changeChange effective 07/25/2025 as recorded in the Policy Update History.

Provider Responsibilities and Reimbursement Actions

Documentation Required

Documentation and claim review

Providers must submit accurate, complete documentation and use correct coding for all services billed. Documentation should support the medical necessity, date of service, specific procedures/tests performed, and any related diagnoses. Use HIPAA-approved code sets and follow industry-standard coding guidelines (e.g., AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG rules, CMS NCCI edits).

Submit supporting clinical records upon request to substantiate billed services
Code claims according to current coding manuals and payer-specific guidance
Claims are subject to review and may be denied, adjusted, or audited if documentation or coding is inaccurate or insufficient

Billing Rule

Reimbursement update actions

Definitions, Symptoms, and Diagnostic Considerations

Plan documents (inv-08)

Certificates of Health Care BenefitsIncluded as a plan document that governs coverage when conflicts arise.

Benefit bookletsListed among plan documents that guide coverage determinations.

Summary Plan DescriptionsSpecifically named as a plan document that will govern in case of conflict with policy.

Other coverage documentsPolicy notes that plan documents include, but are not limited to, the listed items and other coverage documents.

Signs and symptoms (inv-09)

Common respiratory symptomsFever, cough, shortness of breath or difficulty breathing, congestion or runny nose.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy CPCPLABOS7

Change TypeMultiple revisions and removals

Effective DateJul 25, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and coding; claims are subject to review and may require additional documentation.

SourceLink

On This Page

Effective 2025-07-25 this policy updates reimbursement and coverage actions that affect billing and test selection. Providers should stop submitting claims for items removed from coverage and should select from the remaining authorized test codes and methods. Claims for tests or codes removed in the update may be denied. Where tests were reallocated (for example, NAAT added as an acceptable option for specific indications), bill using the appropriate covered code and method. Frequency limits and panel management changes (including tests moved to other policies) must be followed; submit claims in accordance with the revised frequency and coding guidance.

Removed coverage for specified pre-procedure asymptomatic screening and listed codes removed from coverage as of 2025-07-25
Added NAAT as an acceptable test option for MIS-A and MIS-C in applicable coverage criteria — bill the covered NAAT CPT/HCPCS code
Updated allowable frequency (e.g., tests allowed once every 48 hours where specified) — do not bill more frequently
Tests moved to other policies (e.g., CPCPLABO4S Pathogen Panel Testing) should be billed per those policy rules
Whole genome sequencing and other removed items are no longer covered; claims for removed items may be denied
Providers should review the Policy Update History for specific removed codes and date of effect and adjust billing systems accordingly

MIS-C and MIS-A definitions and diagnostic considerations (inv-10)

Age-based case definitionsMIS-C: illness in persons <21 years with specified clinical and laboratory criteria; MIS-A: similar definition for persons ≥21 years, per CDC guidance.

Clinical severity and hospitalizationMIS-C requires clinical severity necessitating hospitalization as one of the CDC criteria.

Multisystem involvementNew onset manifestations in at least two organ-system categories (e.g., cardiac, mucocutaneous, gastrointestinal, hematologic) are required for MIS-C per CDC.

Laboratory and cardiac considerationsEvidence of systemic inflammation (e.g., elevated CRP) and cardiac involvement (e.g., reduced LVEF, coronary artery changes, or elevated troponin) are included in diagnostic considerations.

References (inv-11)

Literature and assay performanceExtensive references provided for analytic and clinical performance of PCR, antigen, RT-LAMP, NAAT/RT-PCR, NGS, pooling strategies, and serology assays.

Regulatory and FDA resourcesMultiple FDA EUA summaries and transition plan documents are cited (e.g., COVIDSeq, pooling assays, EUA summaries).

Professional guidanceGuidance and position statements from CDC, WHO, IDSA, AMA, AAP, ECDC, and specialty organizations are cited for testing and serology use.

MIS-C/MIS-A clinical guidanceReferences include CDC and American College of Rheumatology guidance for MIS-C and related clinical management and diagnostic considerations.

Document update noteReferences were revised in the 07/25/2025 update as noted in the Policy Update History.