CurrentBlue Cross Blue Shield - TexasPolicy CPCPLAB063

Identification of Microorganisms Using Nucleic Acid Probes

This reimbursement policy governs coverage and payment for laboratory tests that identify microorganisms using nucleic acid direct probes, amplified probes, and quantification methods for Blue Cross Blue Shield of Texas members and participating providers.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyIdentification of Microorganisms Using Nucleic Acid Probes

Policy CodePolicy CPCPLAB063

Change TypeMaterial updates and code removals

Effective DateFeb 5, 2025

Next Review Date

Key ActionDo not bill for simultaneous direct probe, amplified probe, and/or quantification for the same organism in a single encounter; submit accurate documentation and valid code combinations.

SourceLink

POLICY UPDATE CHANGES

Removed Mycoplasma genitalium from Table 1 as management for testing is now included in CPCPLAB051 Diagnostic Testing of Common Sexually Transmitted Infections.

Changed direct probe for Herpes virus 6 (87531) from may be reimbursable to is not reimbursable because quantitative testing differentiates active vs latent infection and direct/amplified probe coverage should match for herpes virus 6.

Removed code 87563.

Document updated with literature review and references revised.

~30CPT codes listed in policy

Table 1Reimbursement matrix

Not reimbursableSimultaneous tests

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Coverage Criteria and Billing Rules

Coverage criteria and billing rules

Reimbursement determinations for individual probe tests are specified per organism and modality in Table 1; simultaneous ordering rules apply.

Per Table 1, individual CPT codes are marked as MBR (may be reimbursable) or INR (not reimbursable) depending on organism and modality; coverage varies by code and organism.

Table 1 reimbursement examples (not exhaustive): Bartonella henselae or quintana — Amplified Probe 87471 (MBR); Quantification 87472 (INR). Non-vaginal Candida species — Direct Probe 87480 (INR); Amplified Probe 87481 (INR); Quantification 87482 (INR). Chlamydia pneumoniae — Direct Probe 87485 (MBR); Amplified Probe 87486 (MBR); Quantification 87487 (INR). Clostridium difficile — Amplified Probe 87493 (MBR). Cytomegalovirus — Direct Probe 87495 (MBR); Amplified Probe 87496 (MBR); Quantification 87497 (MBR). Enterovirus — Amplified Probe 87498 (MBR). Enterococcus vancomycin-resistant — Amplified Probe 87500 (MBR). Hepatitis G — Direct Probe 87525 (INR); Amplified Probe 87526 (INR); Quantification 87527 (INR). Herpes-virus-6 — Direct Probe 87531 (INR); Amplified Probe 87532 (INR); Quantification 87533 (MBR). Legionella pneumophila — Direct Probe 87540 (MBR); Amplified Probe 87541 (MBR); Quantification 87542 (INR). Mycoplasma pneumoniae — Direct Probe 87580 (MBR); Amplified Probe 87581 (MBR); Quantification 87582 (INR). Orthopoxvirus — Amplified Probe 87593 (MBR). Respiratory syncytial virus — amplified probe 87634 (MBR). Staphylococcus aureus — amplified probe 87640 (MBR); Staphylococcus aureus, methicillin-resistant — amplified probe 87641 (MBR).

Simultaneous ordering prohibition: Ordering any combination of direct probe, amplified probe, and/or quantification for the same organism during a single encounter is not reimbursable.

Product variation: Not all requirements apply to every product; providers should consult applicable plan documents and provider contracts for product-specific coverage or conflicts with coding edits.

Codes and Simultaneous Test Policy

Listed CPT codes for nucleic acid probe testsCPT

87471	Bartonella henselae or quintana, Amplified Probe
87472	Bartonella henselae or quintana, Quantification
87480	Non-vaginal Candida species, Direct Probe
87481	Non-vaginal Candida species, Amplified Probe
87482	Non-vaginal Candida species, Quantification
87485	Chlamydia pneumoniae, Direct Probe
87486	Chlamydia pneumoniae, Amplified Probe
87487	Chlamydia pneumoniae, Quantification
87493	Clostridium difficile, Amplified Probe
87495	Cytomegalovirus, Direct Probe

1–10 of 30

1/3

Simultaneous test limit

RuleOrdering any combination of direct probe, amplified probe, and/or quantification for the same organism during a single encounter is not reimbursable.

ScopeApplies to tests for the same organism within one clinical encounter (regardless of specimen or panel combinations).

Claims handlingClaims submitted for simultaneous modalities for the same organism are subject to non‑payment and code edits per plan rules and provider contracts.

Documentation, Claim Submission, and Ordering Guidance

Documentation Required

Documentation and claim submission requirements

Providers must submit accurate documentation of services performed and file claims using valid code combinations from HIPAA‑approved code sets. Claims are subject to code edit protocols, plan documents, provider contract language, medical policies, coding software logic, and may be audited; upon request providers should supply additional documentation.

Submit claims using valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD-10).
Claims are subject to code edit protocols, CCI edits, and coding software logic.
When conflicts exist, the applicable plan document or provider contract governs.
Be prepared to provide additional documentation upon request.

Billing Rule

Terms and Probe Modalities

Reimbursement status abbreviations

MBRMay be reimbursable (test may be reimbursable as shown in Table 1).

INRIs not reimbursable (test is not reimbursable as shown in Table 1).

ReferenceReimbursement status abbreviations are used in Table 1 to indicate per‑code coverage determinations for direct, amplified, and quantification probe modalities.

Probe modalities — definitions and role

Direct probeA probe modality listed in Table 1; reimbursement status varies by organism and code (e.g., Cytomegalovirus, Direct Probe = 87495 (MBR)).

Amplified probeA probe modality listed in Table 1 that uses amplification techniques; reimbursement status varies by organism and code (e.g., Enterovirus, Amplified Probe = 87498 (MBR)).