CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO53

Hemolytic Streptococcus Testing

Defines lab reimbursement criteria for detection and testing of hemolytic streptococcal infections for Blue Cross and Blue Shield of Texas members; applies to providers submitting claims to BCBSTX for streptococcal testing.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHemolytic Streptococcus Testing

Policy CodePolicy CPCPLABO53

Change TypeRevised reimbursement languageadded procedure code

Effective DateMay 15, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims are subject to review against benefit coverage, contracts, medical policies, and coding policies.

SourceLink

POLICY UPDATE CHANGES

Updated reimbursement criterion 6.a to include nucleic acid testing as a prior test (now reads: 'As a follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection').

Added procedure code 86581 to the policy.

Document updated with literature review and revised references.

>=10reimbursement rules

1new code added

2update history items

Reimbursement Criteria for Streptococcal Testing

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHemolytic Streptococcus Testing

Policy CodePolicy CPCPLABO53

Change TypeRevised reimbursement languageadded procedure code

Effective DateMay 15, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims are subject to review against benefit coverage, contracts, medical policies, and coding policies.

SourceLink

On This Page

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.

Reimbursable and non-reimbursable scenarios for streptococcal testing

Covered when the following reimbursable and non-reimbursable scenarios apply:

ALL of the following

ANY of the following
- Individual has a modified Centor score of 3 or greater (see Note 1).
- 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.
ANY of the following
- Individual fails to demonstrate clinical improvement.
- Individual has progressive symptoms or clinical deterioration after initiation of antibiotic therapy.
- Cases of suspected prosthetic joint infection.
Skin and/or soft tissue infection bacterial culture (from skin swab or pus) may be reimbursable for streptococcal infection.
ANY of the following
- Serological titer testing.
- Anti-streptolysin O immunoassay.
- Hyaluronidase activity or anti-hyaluronidase immunoassay.
- Streptokinase activity or anti-streptokinase immunoassay.
Bacterial throat culture is not reimbursable for suspected viral pharyngitis.
ALL of the following
- As a follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection.
- As a screening method in an asymptomatic patient.
- For individuals with suspected viral pharyngitis.
Serological titer testing and the named immunoassays (anti-streptolysin O, hyaluronidase activity or anti-hyaluronidase, streptokinase activity or anti-streptokinase) are not reimbursable except as described above for suspected ARF or PSGN.
Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter is not reimbursable.
The following tests are not reimbursable in any situation: panel tests that screen/identify multiple streptococcal strains (including Solana Strep Complete Assay, Lyra Direct Strep Assay), MALDI-TOF identification of streptococcus, quantification of any strain of streptococcus using nucleic acid amplification (including PCR), and nicotinamide-adenine dinucleotide activity or anti-nicotinamide-adenine immunoassay.

Documentation, Claims, and Denial Risks

Documentation Required

Documentation and Claim Submission Responsibilities

Providers are responsible for submitting accurate documentation and correctly coded claims using HIPAA-approved code sets. Claims are subject to review against benefit terms, provider contract language, clinical payment and coding policies, and coding software logic. Upon request, providers should furnish additional documentation to support medical necessity and coding choices to avoid delays or denials.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC as applicable).
Maintain and provide clinical documentation supporting testing rationale, Centor score or clinical findings, and test sequencing when requested.
Claims may be reviewed for compliance with member benefit documents and provider contract terms.

Denial Risk

Reimbursement Denial Risk for RADT in Restricted Scenarios

Rapid antigen diagnostic tests (RADT) for streptococcal infection have defined reimbursement restrictions. RADT performed in scenarios listed as non-reimbursable may be denied. Providers should review the policy conditions before ordering or billing RADT to reduce the risk of claim denial.

RADT is not reimbursable as a follow-up test for individuals who have already had a bacterial culture or a nucleic acid test for streptococcal infection.
RADT is not reimbursable when used as a screening method in an asymptomatic patient.
RADT is not reimbursable for individuals with suspected viral pharyngitis.
Except for asymptomatic children under age three with a mitigating circumstance (e.g., symptomatic household member), RADT in those scenarios above may be denied.
When RADT is performed in non-covered scenarios, document clinical justification; however, expect denial if the service clearly falls into the non-reimbursable categories.

OpenPayer

Hemolytic Streptococcus Testing

Reimbursement Criteria for Streptococcal Testing

Procedure Codes and Scoring Thresholds

Documentation, Claims, and Denial Risks

Clinical Definitions and Scoring Components