ModifiedBlue Cross Blue Shield - TexasPolicy CPCPLAB027

Testing for Diagnosis of Active or Latent Tuberculosis

Defines reimbursement and coding guidance for laboratory testing used to diagnose or screen for latent and active tuberculosis for Blue Cross Blue Shield of Texas members; applies to providers submitting claims under BCBSTX plans.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLAB027

Change TypeAdded codereferences updated

Effective DateFeb 5, 2025

Next Review Date

Key ActionSubmit accurate documentation and provide additional documentation upon request to support claim review and coding compliance.

SourceLink

POLICY UPDATE CHANGES

Added code 87564 to the policy's reimbursement coding.

Document updated with literature review and references revised.

11distinct reimbursement determinations and exclusions listed

~30example CPT/other codes provided

1new CPT/HCPCS code added

1.0document version

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Reimbursement Criteria and Exclusions

Reimbursement criteria and exclusions for TB testing

Reimbursement determinations for tests used to diagnose or screen for latent or active tuberculosis include reimbursable items, conditional reimbursable items, and explicit non-reimbursable tests.

ALL of the following

ANY of the following
- IGRA may be reimbursable to diagnose or screen for latent tuberculosis (TB) infection in: (a) individuals who are at risk for infection with Mycobacterium tuberculosis (Mtb); (b) individuals who are unlikely to be infected with Mtb when screening is obliged by law.
ANY of the following
- For all suspected TB infections, the following tests may be reimbursable: (a) Acid fast bacilli (AFB) smear/stain; (b) Culture and culture-based drug susceptibility testing of Mycobacteria spp.
ANY of the following
- Direct probe or amplified probe nucleic acid-based testing, including PCR, may be reimbursable for Mycobacteria spp, M. tuberculosis, and M. avium intracellulare.
ALL of the following
- ANY of the following
  - Prior TB treatment: The individual has been treated for TB in the past.
  - High-incidence or MDR country: The individual was born in or has lived for at least 1 year in a foreign country with at least a moderate TB incidence (≥20 per 100,000) or a high primary multi-drug resistant (MDR) TB prevalence (≥2%).
  - Contact of MDR-TB case: The individual is a contact of an individual with MDR-TB.
  - HIV infection: The individual is HIV infected.
ALL of the following
- ANY of the following
  - Sputum cultures remain positive after 3 months of treatment.
  - There is bacteriological reversion from negative to positive.
ALL of the following
- For individuals with pleural effusion, pericardial effusion, or ascites and suspected TB infection, cell counts, protein, glucose, and lactate dehydrogenase (LDH) concentrations of cerebrospinal, pleural, peritoneal, pericardial, and other fluids may be reimbursable.
ALL of the following
- In HIV-infected individuals with CD4 cell counts ≤100 cells/microL who have signs and symptoms of tuberculosis, urine-based detection of mycobacterial cell wall glycolipid lipoarabinomannan (LAM) may be reimbursable.

ALL of the following

IGRA for active TB: Interferon gamma release assay (IGRA) is not reimbursable for individuals with active tuberculosis.
Simultaneous duplicate molecular tests: Simultaneous ordering of any combination of direct probe, amplified probe, and/or quantification for the same organism in a single encounter is not reimbursable.
Quantitative nucleic acid testing: Quantitative nucleic acid testing for Mycobacterium spp, M. tuberculosis, and M. avium intracellulare is not reimbursable.
ADA and IFN-gamma in fluids for extrapulmonary TB: Testing of adenosine deaminase (ADA) and interferon-gamma (IFNγ) levels in cerebrospinal, pleural, peritoneal, pericardial, and other fluids for the diagnosis of extrapulmonary TB are not reimbursable.
Serum protein biomarkers/panels for TB diagnosis: Testing of serum protein biomarkers or panels of biomarkers for the detection and diagnosis of TB are not reimbursable.

ALL of the following

Conditions and clinical context must meet the specific criteria above for conditional reimbursements (e.g., AFB smear positivity, HIV with CD4 ≤100 cells/microL, epidemiologic risk factors, or persistent positive cultures).
Simultaneous or duplicate molecular testing and quantitative NAATs for the same organism in a single encounter are specifically excluded from reimbursement regardless of other testing.

Documentation, Claims, and Provider Responsibilities

Documentation Required

Documentation and claim review responsibilities

Providers are responsible for submission of accurate documentation of services performed and are expected to submit claims using valid HIPAA-approved code sets and industry standard coding guidelines. Claims are subject to code edit protocols and claim review (including benefit terms, provider contract language, medical and clinical payment policies, and coding software logic); upon request, providers are urged to submit additional documentation to support the claim.

Submit claims using valid HIPAA-approved code sets and industry standard coding guidelines (e.g., UB, CPT, HCPCS, ICD-10).
Be prepared to provide additional documentation upon request to substantiate medical necessity and coding.
Claims are subject to code edits and review against benefit, contract, and policy rules and may be denied if not supported.

Billing Rule

Coding update — addition of code 87564

The policy was updated to add CPT code 87564 to the reimbursement coding; reimbursement information is otherwise unchanged.

Newly added code: 87564 (policy states code added; description not provided in this segment).
No other changes to reimbursement information were made.

Plan Documents and Reference Sources

Plan documents (definitions) - inv-06: Plan documents

Certificates of Health Care BenefitsIncluded among plan documents that govern member benefits when in conflict with this policy.

Benefit bookletsListed as plan documents that take precedence over this Clinical Payment and Coding Policy in case of conflict.

Summary Plan DescriptionsExplicitly named as plan documents that govern member coverage over this policy when conflicts arise.

Other coverage documentsAny other coverage documents are considered plan documents and will govern if they conflict with this policy.

Governing authorityIf a conflict arises between this policy and a plan document, the plan document will govern; if between this policy and a provider contract, the provider contract will govern.

References / literature - inv-07: References / literature

ATS/CDC/ERS/IDSA guideline (Drug‑Resistant TB)Nahid P. et al., 2019 — Treatment of Drug‑Resistant Tuberculosis. Am J Respir Crit Care Med; provides clinical practice guidance cited in the policy.

NSTC LTBI guidanceNSTC (2023/2024) — Testing and Treatment of Latent Tuberculosis Infection in the United States; cited as a referenced clinical guideline.

WHO consolidated and programmatic guidelinesMultiple WHO documents (2015, 2018, 2021) on latent TB management and rapid diagnostics are cited in the policy's reference list.

Systematic reviews on diagnosticsPai M. et al. (2014, 2016) and Steingart K.R. et al. (2006) — reviews on IGRA, NAAT, and smear microscopy cited as evidence sources.

Urine LAM and diagnostic accuracy studiesNakiyingi L. et al. (2014) and Shah M. et al. (2016) — studies on urine lipoarabinomannan assays referenced for urine LAM use in HIV‑infected individuals.

Epidemiology and susceptibility literaturePeto H.M. et al. (2009) and Zürcher K. et al. (2019) among others — cited for extrapulmonary TB epidemiology and drug susceptibility testing evidence.

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OpenPayer

Testing for Diagnosis of Active or Latent Tuberculosis

Reimbursement Criteria and Exclusions

Procedure and Reimbursement Codes

Documentation, Claims, and Provider Responsibilities

Plan Documents and Reference Sources