CurrentBlue KCPolicy POL-PP-269

Coronavirus Testing in the Outpatient Setting

Defines Blue KC's reimbursement stance for coronavirus testing in the outpatient setting for medical decision-making purposes and which lines of business and provider types are impacted.

Policy Summary

PayerBlue KC

PolicyCoronavirus Testing in the Outpatient Setting

Policy CodePolicy POL-PP-269

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateJul 1, 202618d

Key ActionReimburse targeted nucleic acid testing (e.g., RT-PCR) for symptomatic individuals and for asymptomatic exposed individuals unless prior infection within 90 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Every 48 hoursMax antigen frequency

90 daysPrior infection exclusion window

~15 codesExample test codes

Commercial + MA + ACALines of business

Outpatient coronavirus testing coverage criteria

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Outpatient coronavirus testing coverage criteria

When testing may or may not be reimbursed for outpatient medical decision-making:

Targeted nucleic acid testing reimbursed for individuals displaying signs or symptoms of possible COVID-19 infection (See Note 1).

Targeted nucleic acid testing reimbursed for asymptomatic individuals with known exposure to COVID-19, EXCEPT when the individual has had a previous COVID-19 infection within the last 90 days.

Targeted nucleic acid testing reimbursed for individuals with signs or symptoms of SARS and who have traveled to endemic areas or been exposed to persons with SARS.

Targeted nucleic acid testing reimbursed for individuals with signs or symptoms of MERS and who have traveled to endemic areas or been exposed to persons with MERS.

To support diagnosis of MIS-C, MIS-A, or PASC, nucleic acid amplification testing and host antibody serology testing may be reimbursed.

For symptomatic individuals, antigen-detecting diagnostic tests for SARS-CoV-2 may be reimbursed once every 48 hours.

Whole genome sequencing of paired specimens for diagnosis of SARS-CoV-2 reinfection is not reimbursed.

For all other situations not described above, host antibody serology testing may not be reimbursed.

In the outpatient setting, SARS-CoV-2 genotyping may not be reimbursed; neutralization antibody testing for SARS-CoV-2 may not be reimbursed; and testing for other endemic coronaviruses (e.g., 229E, NL63, OC43, HKU1) may not be reimbursed.

SARS-CoV-2 test codes and coding limits

Listed SARS-CoV-2 test codesmixed

86328	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19)
86408	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); screen
86409	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); titer
86413	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody, quantitative
86769	Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
87426	Infectious agent antigen detection by immunoassay technique; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2)
87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique
87913	Infectious agent genotype analysis by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), mutation identification in targeted region(s)
U0001	CDC Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel
U0002	Non-CDC laboratory test for 2019-nCoV (COVID-19), any method

Antigen test frequency limit

Frequency limit for symptomatic antigen testsAntigen-detecting diagnostic tests for symptomatic individuals may be reimbursed once every 48 hours

ScopeApplies only to outpatient testing for medical decision-making; does not address work, school, or mandated testing

DependencyApplication depends on individual’s benefit coverage at time of request

Reimbursement conditions, exceptions, and non-covered tests — provider impact

Billing Rule

Reimbursement conditions and exceptions

Targeted nucleic acid testing (e.g., RT‑PCR, rapid molecular tests) for SARS‑CoV‑2 may be reimbursed when performed for medical decision making in the outpatient setting in the following situations: symptomatic individuals (see Note 1); asymptomatic individuals with known exposure to COVID‑19 (except if prior COVID‑19 infection within the last 90 days); individuals with signs/symptoms and travel or exposure risk for SARS or MERS (targeted NAAT such as RT‑PCR may be reimbursed); to support diagnosis of MIS‑C, MIS‑A, or post‑acute sequelae of SARS‑CoV‑2 infection (PASC) when NAAT and host antibody serology testing are used; and symptomatic individuals using antigen diagnostic tests up to once every 48 hours. Whole genome sequencing of paired specimens to diagnose SARS‑CoV‑2 reinfection is not reimbursed.

Applicable only for outpatient medical decision-making testing (not for work/school/state/federally mandated testing)
Asymptomatic exposed individuals are reimbursed except when prior infection occurred within 90 days
Antigen-detecting diagnostic tests for symptomatic individuals reimbursed once every 48 hours
Whole genome sequencing for reinfection diagnosis (paired specimens from distinct lineages) is not reimbursed

Denial Risk

Non‑covered tests

The following tests do not meet coverage criteria and will not be reimbursed in the outpatient setting due to insufficient evidence of clinical utility: SARS‑CoV‑2 genotyping; neutralization antibody testing for SARS‑CoV‑2; and testing for other endemic coronaviruses (e.g., 229E, NL63, OC43, HKU1).

SARS‑CoV‑2 genotyping — not reimbursed
Neutralization antibody testing for SARS‑CoV‑2 — not reimbursed
Endemic coronavirus panels (229E, NL63, OC43, HKU1) — not reimbursed

Key definitions

Targeted nucleic acid testing

DefinitionMolecular tests such as reverse transcription polymerase chain reaction (RT‑PCR) and rapid molecular tests used to detect SARS‑CoV‑2 RNA

PurposeTargeted nucleic acid testing reimbursed to detect active SARS‑CoV‑2 infection for symptomatic individuals and select exposed or travel‑related scenarios

ExamplesRT‑PCR and rapid molecular amplification tests (nucleic acid–based methods)

MIS‑C / MIS‑A definitions

MIS‑C definition (CDC criteria)Illness in persons <21 years with fever ≥38°C, clinical severity requiring hospitalization, elevated CRP (systemic inflammation), and new onset manifestations in ≥2 organ systems (e.g., cardiac, mucocutaneous, gastrointestinal, hematologic)

MIS‑A definition (CDC criteria)Illness in persons ≥21 years with hospitalization ≥24 hours, fever ≥38°C, laboratory evidence of severe inflammation, and multisystem clinical criteria (primary and secondary) as specified by CDC

Use for reimbursementNucleic acid amplification testing and host antibody serology may be reimbursed to support diagnosis of MIS‑C or MIS‑A