ModifiedBlue Cross Blue Shield - TexasPolicy CPCPLABO4S

Pathogen Panel Testing Reimbursement

Defines outpatient laboratory reimbursement criteria for multiplex and antigen pathogen panel testing and lists covered and non-reimbursable testing scenarios for Blue Cross Blue Shield of Texas members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPathogen Panel Testing Reimbursement

Policy CodePolicy CPCPLABO4S

Change TypeMaterial revisions and code updates

Effective DateSep 26, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and use the updated code list when billing; claims may require additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Revised reimbursement statements to allow multiplex PCR-based testing of up to 5 respiratory pathogens for symptomatic individuals and up to 25 respiratory pathogens for immunocompromised symptomatic individuals, and disallow testing of 6 or more respiratory pathogens in other situations.

Added a Note listing signs and symptoms of respiratory tract infection to support clinical criteria.

Added several molecular test codes (including 87428, 0202U, 0223U, 0225U, 0556U, 0563U, 0564U, 0590U, 0593U) and removed others; see policy history for specifics.

up to 5symptomatic — reimbursable

up to 25immunocompromised — reimbursable

6+not reimbursable (other situations)

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Coverage and Reimbursement Criteria

Outpatient pathogen panel reimbursement criteria

Covered when ALL of the following are met:

ALL of the following

ONE OF
ALTERNATIVE FOR IMMUNOCOMPROMISED
EXCLUSIONS - NOT REIMBURSABLE

Respiratory panel reimbursement criteria

Reimbursement for multiplex respiratory pathogen panels is determined by clinical scenario and panel size as follows:

ALL of the following

For individuals displaying signs and symptoms of a respiratory tract infection (see Note 1), multiplex PCR-based testing of up to 5 respiratory pathogens may be reimbursable.
For immunocompromised individuals displaying signs and symptoms of a respiratory tract infection (see Note 1), multiplex PCR-based panel testing of up to 25 respiratory pathogens may be reimbursable.
For all situations not described above, antigen panel testing or multiplex PCR-based panel testing of 6 or more respiratory pathogens is not reimbursable.

Coding and Code Lists

Listed laboratory/pathogen panel CPT Category III codesCPT

0112U
0115U
0140U
0141U
0142U
0152U
0202U
0223U
0225U
0321U

1–10 of 22

1/3

Listed molecular test codes (added)mixed

87428	Molecular diagnostic code listed as added in policy update history
0202U	Molecular diagnostic code listed as added in policy update history
0223U	Molecular diagnostic code listed as added in policy update history
0225U	Molecular diagnostic code listed as added in policy update history
0556U	Molecular diagnostic code listed as added in policy update history
0563U	Molecular diagnostic code listed as added in policy update history
0564U	Molecular diagnostic code listed as added in policy update history
0590U	Molecular diagnostic code added effective 10/01/2025
0593U	Molecular diagnostic code added effective 10/01/2025

inv-05: max_resp_pathogens_non_immunocompromised

Maximum pathogens reimbursableUp to 5 respiratory pathogens for symptomatic non-immunocompromised individuals (antigen testing or multiplex PCR-based panel testing)

Applicable settingOutpatient testing only; criteria do not apply to other settings

Supporting noteSigns and symptoms must meet Note 1 definition of respiratory tract infection

inv-06: max_resp_pathogens_immunocompromised

Maximum pathogens reimbursableUp to 25 respiratory pathogens for symptomatic immunocompromised individuals (multiplex PCR-based panel testing)

Test type requiredMultiplex PCR-based panel testing (specified for immunocompromised patients)

Documentation, Billing, and Provider Guidance

Documentation Required

Documentation and claim submission — provider responsibilities

Providers are responsible for submitting accurate and complete documentation to support services billed. Claims must be coded using HIPAA-compliant code sets and in accordance with industry-standard coding guidelines (for example: Uniform Billing, AMA CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG guidance, CMS National Correct Coding Initiative and CCI edits). Claims are subject to review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should furnish additional documentation to support medical necessity, code selection, and service details. Failure to supply required documentation or to code services appropriately may result in claim denial or recoupment.

Submit documentation that clearly supports service(s) rendered, diagnosis, and medical necessity.
Code claims using HIPAA approved code sets and follow industry standard coding guidelines (CPT, HCPCS, ICD-10, NDC, DRG, CMS/CCI).
Retain and provide records when requested for claim review or audit to avoid denials or delays.

Definitions and Clinical Notes

inv-12: Signs and symptoms of a respiratory tract infection

Common symptomsFever, chills, fatigue, cough, rhinorrhea

Neurologic/sensoryNew ageusia or anosmia, headaches, myalgia

Gastrointestinal/constitutionalAnorexia, vomiting, diarrhea, weakness

Pediatric/infant signsIrritability, poor feeding, tachypnea, chest retractions, wheezing, cyanosis; infants may show lethargy or fussiness

inv-13: respiratory tract infection (signs and symptoms)

Purpose of noteProvides the clinical signs and symptoms that qualify as a respiratory tract infection for reimbursement consideration

Billing Rule

Billing/code updates and usage guidance

Billing and code usage for respiratory pathogen panel testing has been updated over time; providers should bill only for codes that match the panel size and clinical scenario described by the policy and aligned effective dates. Refer to the policy’s update history for code additions/removals and effective dates when submitting claims. Antigen or multiplex PCR panel testing of 6 or more respiratory pathogens is generally not reimbursable except as specifically allowed (see Reimbursement Information) — smaller panels (up to 5 pathogens) or expanded panels (up to 25 pathogens) may be reimbursable in defined clinical situations (e.g., symptomatic individuals or immunocompromised patients).

Review Policy Update History for code changes and effective dates before billing (examples: 09/26/2025 additions; 08/01/2025 additions; prior 2025/2024 changes).
Bill using the specific CPT/HCPCS/unique codes that correspond to the exact multiplex/antigen panel performed. Do not bill for a larger panel when a smaller reimbursable panel was performed.
Where the policy limits reimbursement by panel size or clinical condition, ensure clinical documentation (signs/symptoms, immunocompromised status, outpatient setting as applicable) is present on the record to justify the billed code.
If a code was removed from the policy effective date, do not bill that code for dates of service on/after its removal; if a code was added effective a future date, do not bill it before that date.