CurrentOscar HealthPolicy N/A

Sexually Transmitted Infection (STI) Testing — Nucleic Acid (DNA/RNA) Reimbursement

This document governs reimbursement and coding rules for nucleic acid (DNA/RNA) sexually transmitted infection (STI) testing for Oscar Health providers, describing when single-test CPT codes are bundled into a comprehensive panel and how claims will be adjudicated.

Policy Summary

PayerOscar Health

PolicySTI nucleic acid testing reimbursement and bundling rules

Policy CodePolicy N/A

Change TypeMinor/technical (no material coverage change)

Effective DateFeb 1, 2026

Next Review DateOct 6, 2025

Key ActionIf two or more single-test CPT codes (87491, 87591, 87661) are billed by the same provider on the same date of service and CPT 87801 is not present, deny the single-test lines and require provider to resubmit a corrected claim with CPT 87801.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 87801Comprehensive multiple-organism code used for reimbursement when multiple single tests billed

87491, 87591, 87661Single-organism CPT codes considered components of a bundled panel

2+Threshold at which services are bundled

Single unit paidPayment unit

Coverage and Claim Adjudication Rules

Policy Summary

PayerOscar Health

PolicySTI nucleic acid testing reimbursement and bundling rules

Policy CodePolicy N/A

Change TypeMinor/technical (no material coverage change)

Effective DateFeb 1, 2026

Next Review DateOct 6, 2025

SourceLink

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Reimbursement and claim adjudication rules for nucleic acid testing for infectious agents (STI testing).

ALL of the following

Oscar will reimburse the more comprehensive multiple-organism CPT code 87801 (Infectious agent detection by nucleic acid; amplified probe technique) when two or more single-organism nucleic acid test CPT codes (for example, 87491, 87591, 87661) are billed separately by the same provider on the same date of service.
If a claim is received with two or more of the single test codes (CPT 87491, CPT 87591, and/or CPT 87661) on the same date of service by the same provider and the comprehensive code CPT 87801 is not present on the claim, the claim lines will be denied; the provider must resubmit the claim with the appropriate comprehensive code (CPT 87801).
Operational: denial requires resubmission with CPT 87801.
Reimbursement will be made based on a single unit of CPT 87801 regardless of the number of units billed for a single test code on the original claim.
Modifiers will not override the bundling edit — no modifier will change the requirement to bill CPT 87801 when two or more single test codes are present for the same date of service by the same provider.

Relevant CPT Codes and Bundling Rules

Single STI CPT codesCPTCovered

87491	Infectious agent detection by nucleic acid (DNA or RNAJ; Chlamydia trachomatis, amplified probe technique
87661	Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique
87591	Infectious agent detection by nucleic acid (DNA or RNAJ; Neisseria gonorrhoeae, amplified probe technique

Comprehensive STI CPT codeCPTCovered

87801

Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique

Bundling threshold

Bundling ruleTwo or more single-test CPT codes billed by the same provider on the same date of service are bundled into CPT 87801.

Affected single-test CPT codesCPTs 87491, 87591, 87661 are considered component tests for bundling determination.

Payment unitReimbursement will be made as a single unit of CPT 87801 regardless of units billed for individual single-test codes.

Claim handling when comprehensive code not billedIf CPT 87801 is not present when two or more single-test codes are submitted, the single-test lines will be denied and require corrected claim resubmission with CPT 87801.

Billing Actions and Modifier Guidance

Denial Risk

Resubmit claim with CPT 87801 when panel not billed

If two or more single-test CPT codes (87491, 87591, 87661) are billed by the same provider on the same date of service and CPT 87801 is not present on the claim, the single-test lines will be denied and the provider must resubmit a corrected claim with the comprehensive code (CPT 87801).

Applies when two or more of CPTs 87491, 87591, 87661 are reported by the same provider on the same date of service.
Resubmit a corrected claim that includes CPT 87801 to obtain reimbursement.

Billing Rule

Modifiers do not override bundle edit

No modifiers will override the bundle edit; modifiers cannot be used to bypass bundling of single-test CPTs into CPT 87801.

Key Terms

Nucleic acid assays (definition)

DefinitionTests that utilize DNA or RNA to detect infectious agents (nucleic acid assays).

Billing guidanceThese services should be billed with appropriate CPT codes and adhere to correct coding rules; component tests that are part of a panel should be billed with the comprehensive panel code rather than separately.

PurposeUsed for detection of sexually transmitted infections (STIs) via nucleic acid amplification or probe techniques.

Panel bundling

Panel bundling ruleWhen two or more single-test CPT codes for STI detection are billed together by the same provider on the same date of service, they are considered part of a laboratory panel and are bundled into the comprehensive CPT 87801.

Denial and resubmissionIf the comprehensive CPT 87801 is not billed with two or more single-test codes, the single-test lines will be denied and the provider must resubmit a corrected claim including CPT 87801.

Modifier policyNo modifiers will override the bundle edit; modifiers do not prevent bundling into CPT 87801.