CurrentBlue KCPolicy POL-PP-260

β-Hemolytic Streptococcus Testing

Coverage and reimbursement criteria for laboratory testing to detect β-hemolytic Streptococcus (including Group A, B, C/G and related serologic assays) for Blue KC members and impacted provider types.

Policy Summary

PayerBlue KC

Policyβ-Hemolytic Streptococcus Testing

Policy CodePolicy POL-PP-260

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateOct 1, 2026

Key ActionDocument clinical justification (modified Centor score ≥3, absence of viral features, or RADT-negative symptomatic child/adolescent) when ordering throat swab bacterial culture.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10/1/2026policy review cycle

Facility & Professionalproviders impacted

~20listed procedure codes

POL-PP-260 / AHS-G2159internal policy reference

Coverage Criteria

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.

inv-01: Throat Swab Bacterial Culture — Covered Indications

Bacterial culture testing from a throat swab for respiratory illness is reimbursed when ANY of the following are met:

Throat swab culture reimbursement: Individual has a modified Centor criteria score of 3 or greaterCentor >=3

See Note 1 for Centor components

Throat swab culture reimbursement: Individual is suspected of having bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea)

Throat swab culture reimbursement: Following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent

inv-02: Skin/Soft Tissue and Post-Streptococcal Conditions — Covered Indications

For skin and soft tissue infections and certain post-infectious conditions:

Skin/soft tissue testing: Bacterial culture testing from a skin swab or from pus may be reimbursed for skin and/or soft tissue infections

Serologic testing for suspected ARF/PSGN: For individuals with suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), the following may be reimbursed: serological titer testing; anti-streptolysin O immunoassay; hyaluronidase activity or anti-hyaluronidase immunoassay; streptokinase activity or anti-streptokinase immunoassay

For detection of streptococcal infection causing respiratory illness, throat swab bacterial culture is reimbursed when any one of the following is documented: a modified Centor score ≥ 3 (see Note 1); clinical suspicion of bacterial pharyngitis in the absence of viral features (for example, cough, oral ulcers, rhinorrhea); or following a negative RADT in a symptomatic child or adolescent. Document the clinical justification (modified Centor components or absence of viral features) on the order to support reimbursement.

Except for asymptomatic children under age three with a mitigating circumstance (for example, a symptomatic household contact), RADT is not reimbursed when used as a screening method in an asymptomatic patient or when used as a follow-up test after a bacterial culture or nucleic acid test. Serological titer testing is also not reimbursed except where specifically described (e.g., suspected ARF or PSGN).

For skin and soft tissue infections, bacterial culture from a skin swab or pus may be reimbursed. For suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), serologic testing including antistreptolysin O and specified enzyme or antibody assays may be reimbursed when clinically indicated.

The following test types are not covered or may be denied: panel tests that screen for and identify multiple streptococcal strains (e.g., assays that simultaneously report group A, B, C/G and α-hemolytic Streptococcus using immunoassay or nucleic acid methods).

Quantification of streptococcal strains by nucleic acid amplification (including PCR) is not reimbursed. Likewise, assays measuring nicotinamide-adenine dinucleotidase activity or anti-nicotinamide-adenine immunoassays are not reimbursed.

Simultaneous ordering of both direct probe and amplified probe nucleic acid tests for the same organism during a single encounter may not be reimbursed. Providers should order only the single, clinically indicated modality consistent with the coverage criteria.

inv-14: Detection of streptococcal infection for respiratory, skin/soft tissue, or suspected ARF/PSGN when clinical criteria met

Detection of streptococcal infection for respiratory, skin/soft tissue, or suspected ARF/PSGN when clinical criteria met — follow the clinical pathways below:

Modified Centor assessment: Assess modified Centor criteria (tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough); score ≥3 supports throat swab culture reimbursementCentor >=3

See Note 1 for Centor components

Clinical absence of viral features: If suspected bacterial pharyngitis, document absence of viral features (e.g., cough, oral ulcers, rhinorrhea) to support culture testing

Pediatric RADT pathway: In symptomatic children/adolescents perform RADT first; if RADT is negative, bacterial culture testing from a throat swab may be reimbursed

Step: RADT → culture in symptomatic pediatric patients

Covered Indications

inv-14: Detection of streptococcal infection causing respiratory illness, skin/soft tissue infection, or suspected ARF/PSGN when clinical criteria met

Detection of streptococcal infection causing respiratory illness, skin/soft tissue infection, or suspected ARF/PSGN is covered when clinical criteria are documented:

Respiratory infection — throat swab culture: Throat swab bacterial culture when one of the following is met: modified Centor score ≥3; suspected bacterial pharyngitis without viral features; or following a negative RADT in a symptomatic child/adolescentCentor >=3 for one pathway

Document Centor components or absence of viral features; follow RADT then culture pathway for children

Skin/soft tissue infection: Bacterial culture testing from skin swab or pus for skin/soft tissue infections

Suspected ARF/PSGN serology: For suspected acute rheumatic fever or post-streptococcal glomerulonephritis, serological titer testing and specific immunoassays (anti-streptolysin O, hyaluronidase, streptokinase activity or corresponding immunoassays) may be reimbursed

Exclusions and limits: RADT is not reimbursed as a follow-up to culture or nucleic acid testing or as asymptomatic screening (except certain asymptomatic children <3 with mitigating circumstance); simultaneous ordering of direct and amplification probe for same organism may not be reimbursed; panel tests and certain quantification assays are not reimbursed

See policy for tests not reimbursed and exceptions

Coding

Listed CPT/HCPCS CodesCPT

86060	Antistreptolysin O; titer
86063	Antistreptolysin O; screen
86215	Deoxyribonuclease, antibody
86317	Immunoassay for infectious agent antibody, quantitative, not otherwise specified
86581	Streptococcus pneumoniae antibody (IgG), serotypes, multiplex immunoassay, quantitative
87040	Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate)
87070	Culture, bacterial; any other source except urine, blood, or stool, aerobic, with isolation and presumptive identification of isolates
87071	Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood, or stool
87077	Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87081	Culture, presumptive, pathogenic organisms, screening only

1–10 of 18

1/2

inv-06: Modified Centor score — threshold value (>= 3)

Threshold for throat swab culture reimbursement>= 3 (modified Centor score)

Where recordedDocument modified Centor score in clinical record or order

Related noteSee Note 1 for Centor components (tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough)

Provider Actions & Documentation

Denial Risk

RADT denial triggers

RADT not reimbursed in specific follow-up or repeat scenarios. RADT will not be reimbursed when performed as a follow-up test for individuals who have already had either a bacterial culture test or a nucleic acid test (NAAT) for a streptococcal infection. RADT is also not reimbursed as a screening method in an asymptomatic patient. Additionally, RADT is not reimbursed for asymptomatic children under age three years except when a mitigating circumstance exists (for example, a symptomatic household contact).

Not reimbursed as follow-up after bacterial culture or NAAT
Not reimbursed for asymptomatic screening
Exception: asymptomatic children <3 years only with mitigating circumstance (e.g., symptomatic family member)

Denial Risk

Panel / quantification and specific assays denial triggers

Panel and quantitative NAAT assays and certain enzymatic/immunoassays are not reimbursed. Panel tests that screen and identify multiple streptococcal strains (e.g., assays that detect group A, B, C/G, α-hemolytic strains) using immunoassay or nucleic acid methods are not covered. The quantification of any streptococcal strain by nucleic acid amplification (including PCR) is not reimbursed. Nicotinamide-adenine dinucleotidase activity testing or anti-nicotinamide-adenine immunoassay is also not covered. For all other situations not explicitly listed as covered, serological titer testing and the listed enzymatic/immunoassays are not reimbursed.

Panel assays that detect multiple streptococcal strains (e.g., Solana Strep Complete, Lyra Direct Strep) — not reimbursed
Quantification of streptococcal strains by NAAT/PCR — not reimbursed
Nicotinamide-adenine dinucleotidase activity or anti-nicotinamide-adenine immunoassay — not reimbursed
Serological titer testing and certain enzymatic/immunoassays — not reimbursed unless explicitly listed as reimbursable

Documentation Required

Required clinical documentation

Document clinical justification when ordering culture testing for suspected streptococcal respiratory infection. Reimbursement for bacterial culture from a throat swab requires one of the following: a modified Centor score of 3 or greater; clinical suspicion of bacterial pharyngitis in the absence of viral features (for example, cough, oral ulcers, rhinorrhea); or following a negative RADT in a symptomatic child or adolescent. For skin/soft tissue infections, document the suspected streptococcal source (skin swab or pus). For suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), document the indication for serological titer testing, anti-streptolysin O immunoassay, hyaluronidase or streptokinase activity testing as applicable. Note: Centor criteria include tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough (one point each).

Modified Centor score >= 3 (document score and component findings)
Absence of viral features (e.g., no cough, no rhinorrhea, no oral ulcers) when bacterial pharyngitis suspected
RADT-negative symptomatic child/adolescent (document RADT result and symptoms)
For skin/soft tissue infections: document source (skin swab or pus) and clinical suspicion
For ARF/PSGN: document specific serologic/assay indication

Billing Rule

RADT then culture in pediatric symptomatic patients

In pediatric and adolescent symptomatic patients, perform RADT first; a negative RADT may justify performing and reimbursing a subsequent bacterial culture. Culture reimbursement is allowed following a negative RADT in a symptomatic child or adolescent. Do not perform RADT as a follow-up after culture or NAAT.

Order RADT first in symptomatic pediatric/adolescent patients
If RADT negative, bacterial culture of a throat swab may be performed and reimbursed
RADT should not be ordered as follow-up after culture or NAAT

Background

Streptococcus are Gram-positive, catalase-negative bacteria that are commonly classified by hemolysis pattern (for example, β-hemolytic species such as Group A [S. pyogenes] and Group B [S. agalactiae], as well as groups C/G and certain α-hemolytic Streptococcus). These organisms cause a range of clinical syndromes including pharyngitis, skin and soft tissue infections, and post-infectious complications such as acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis (PSGN).

Common diagnostic methods addressed by this policy include bacterial culture, rapid antigen diagnostic testing (RADT), serologic assays (for example, antistreptolysin O titers and hyaluronidase/streptokinase activity or immunoassays), and nucleic acid–based tests. Coverage is tied to clinical indications because the choice and interpretation of these tests depend on the presenting syndrome and pretest probability (for example, modified Centor criteria for pharyngitis).

OpenPayer

β-Hemolytic Streptococcus Testing

Coverage Criteria

Covered Indications

Coding

Provider Actions & Documentation

Ordering Requirements

Not Covered

Background

Definitions

Frequency Limits