CurrentBlue KCPolicy POL-PP-287

Identification of Microorganisms Using Nucleic Acid Probes

Payment policy governing reimbursement of nucleic acid probe tests (direct, amplified, quantification) for identification of specific microorganisms for Blue KC lines of business and provider types.

Policy Summary

PayerBlue KC

PolicyIdentification of Microorganisms Using Nucleic Acid Probes

Policy CodePolicy POL-PP-287

Change TypeInitial publication with Avalon updates

Effective Date07/01/2025

Next Review Date07/01/2026

Key ActionDo not bill amplified probe and quantification for the same organism in a single encounter — simultaneous ordering may not be reimbursed.

SourceLink

POLICY UPDATE CHANGES

Initial version published with Avalon 3rd QTR updates.

Version 002policy version

Activepolicy status

2026-07-01next review date

16 codescoding scope

Organism-specific Coverage Criteria

Organism-specific coverage criteria

Coverage status by organism and technique; MCC = may be reimbursed, DNMCC = may not be reimbursed. Specific CPT codes are associated with amplified and quantification tests where indicated.

ALL of the following

Bartonella henselae or quintana
Technique-specific
- Direct probe: not listed
- Amplified probe: 87471 (MCC)
- Quantification: 87472 (DNMCC)

ALL of the following

Chlamydia pneumoniae
Technique-specific
- Direct probe: 87485 (DNMCC)
- Amplified probe: 87486 (MCC)
- Quantification: 87487 (DNMCC)

ALL of the following

Clostridium difficile
Technique-specific
- Direct probe: not listed
- Amplified probe: 87493 (MCC)
- Quantification: not listed

ALL of the following

Cytomegalovirus
Technique-specific
- Direct probe: 87495 (DNMCC)
- Amplified probe: 87496 (MCC)
- Quantification: 87497 (MCC)

ALL of the following

Enterococcus, vancomycin-resistant (e.g., vanA, vanB)
Technique-specific
- Direct probe: not listed
- Amplified probe: 87500 (MCC)
- Quantification: not listed

ALL of the following

Enterovirus
Technique-specific
- Direct probe: not listed
- Amplified probe: 87498 (MCC)
- Quantification: not listed

ALL of the following

Hepatitis G
Technique-specific
- Direct probe: 87525 (DNMCC)
- Amplified probe: 87526 (DNMCC)
- Quantification: 87527 (DNMCC)

ALL of the following

Herpes virus-6
Technique-specific
- Direct probe: 87531 (DNMCC)
- Amplified probe: 87532 (DNMCC)
- Quantification: 87533 (MCC)

ALL of the following

Legionella pneumophila
Technique-specific
- Direct probe: 87540 (DNMCC)
- Amplified probe: 87541 (MCC)
- Quantification: 87542 (DNMCC)

ALL of the following

Orthopoxvirus
Technique-specific
- Direct probe: not listed
- Amplified probe: 87593 (MCC)
- Quantification: not listed

ALL of the following

Mycoplasma pneumoniae
Technique-specific
- Direct probe: 87580 (DNMCC)
- Amplified probe: 87581 (MCC)
- Quantification: 87582 (DNMCC)

ALL of the following

Respiratory syncytial virus
Technique-specific
- Direct probe: not listed
- Amplified probe: 87634 (MCC)
- Quantification: not listed

ALL of the following

Staphylococcus aureus
Technique-specific
- Direct probe: not listed
- Amplified probe: 87640 (MCC)
- Quantification: not listed

ALL of the following

Staphylococcus aureus, methicillin resistant
Technique-specific
- Direct probe: not listed
- Amplified probe: 87641 (MCC)
- Quantification: not listed

CPT Codes and Coding Rules

Listed organism-specific nucleic acid probe CPT codesCPTCovered

87471	Bartonella henselae and Bartonella quintana, amplified probe technique
87472	Bartonella henselae and Bartonella quintana, quantification
87486	Chlamydia pneumoniae, amplified probe technique
87487	Chlamydia pneumoniae, quantification
87493	Clostridium difficile, toxin gene(s), amplified probe technique
87496	Cytomegalovirus, amplified probe technique
87497	Cytomegalovirus, quantification
87498	Enterovirus, amplified probe technique (includes RT when performed)
87500	Vancomycin resistance (e.g., enterococcus vanA, vanB), amplified probe technique
87533	Herpes virus-6, quantification

1–10 of 16

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Concurrent test reimbursement limit — amplified probe and quantification

RuleWhen an amplified probe and a quantification test are ordered for the same organism in a single patient encounter, reimbursement may be denied.

ScopeApplies to simultaneous amplified probe and quantification CPT codes for the same organism on the same date of service.

Action for providersAvoid ordering both an amplified probe and its corresponding quantification for the same organism in one encounter unless documentation justifies separate clinically necessary testing.

Payment implicationClaims for both services in the same encounter may not be reimbursed; submit only the medically necessary test or provide supporting documentation if both are clinically required.

Coverage Determination & Billing Guidance

Note

Coverage determination and payment status

Coverage is determined by the member's benefit plan, date of service, eligibility, and provider agreement. The table below summarizes coverage status for nucleic acid tests using directed probe, amplified probe, and quantification by organism. "MCC" indicates the test may be reimbursed; "DNMCC" indicates the test may not be reimbursed. Providers must verify coverage and obtain any required prior authorization before performing or billing for testing.

Action: Verify member benefits and eligibility at the time of service.
Action: Confirm provider agreement with Blue KC and obtain prior authorization when required.
Action: Do not assume reimbursement solely because a CPT code is listed as MCC; confirm based on the individual member's plan.

Denial Risk

Concurrent amplified probe and quantification ordering

Simultaneous ordering of an amplified probe test and a quantification test for the same organism in a single encounter may not be reimbursed. Submitting both tests together creates a denial risk; order only the test clinically indicated and document the medical necessity clearly if both are requested.

Affected codes (examples from policy): 87581 (Mycoplasma pneumoniae, Amplified Probe) — MCC; 87582 (Mycoplasma pneumoniae, Quantification) — DNMCC.
Billing risk: When both amplified probe and quantification are billed for the same organism on the same date of service, one or both may be denied.
Recommendation: If quantification is needed after an amplified probe confirms presence, submit as a separate encounter with supporting documentation.

Definitions

MCC / DNMCC definitions

MCC (May be reimbursed)Tests labeled MCC in the organism-specific coverage table are considered reimbursable when they meet benefit, eligibility, and documentation requirements.

DNMCC (May not be reimbursed)Tests labeled DNMCC in the organism-specific coverage table are considered not reimbursable under this policy.

Determination basisCoverage designation (MCC or DNMCC) is applied per organism and technique (direct probe, amplified probe, quantification) as listed in the policy table.

Nucleic acid hybridization

DefinitionNucleic acid hybridization techniques use complementary properties of DNA double-helix structures to anneal DNA fragments from different sources.

Common methodsExamples include polymerase chain reaction (PCR) and fluorescent resonance energy transfer (FRET), which utilize hybridization for microorganism identification.

Policy scopeThis policy reviews individual probe tests (not multiplex panels); not all infectious agents detectable by probe techniques are discussed.