DraftPriority HealthPolicy BILLING POLICY No. 152

Diagnosis of Vaginitis

This billing policy governs coding, documentation, and reimbursement considerations for diagnostic testing related to vaginitis (infectious and non-infectious) for Priority Health providers; it affects providers submitting claims and laboratories performing related testing.

Policy Summary

PayerPriority Health

PolicyDiagnosis of Vaginitis

Policy CodePolicy BILLING POLICY No. 152

Change TypeNo material changes

Effective DateAug 2025

Next Review DateNone yet recorded

Key ActionObtain a PreService Organization Determination (PSOD) for Medicare indications not covered by NCD/LCD or this policy when authorization may be required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40+listed CPT/HCPCS and proprietary test codes referenced

Nonereview dates recorded

1related billing policy referenced

Coverage and Documentation Requirements

Coverage and documentation requirements

Coverage depends on the member's benefit plan and sufficient documentation; CPT/HCPCS listing is informational and inclusion does not imply coverage.

Policy Summary

PayerPriority Health

PolicyDiagnosis of Vaginitis

Policy CodePolicy BILLING POLICY No. 152

Change TypeNo material changes

Effective DateAug 2025

Next Review DateNone yet recorded

Key ActionObtain a PreService Organization Determination (PSOD) for Medicare indications not covered by NCD/LCD or this policy when authorization may be required.

SourceLink

On This Page

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.

Coverage is determined by the specific member benefit plan and applicable laws; inclusion of a CPT/HCPCS code in this policy does not indicate that the service is covered or guarantees reimbursement.

Provider must maintain complete and thorough documentation to substantiate the procedure performed and to support medical necessity.

ALL of the following

Documentation must include the specific clinical indications for testing (e.g., clinical suspicion of a pathogen as the cause of the member's condition).
When molecular testing evaluates more than one pathogen, the provider must document why multiplex testing is necessary for clinical management or why single‑pathogen testing is not reasonable and necessary for the specific infection, individual, or indication.

ALL of the following

Apply modifiers only when supported by documentation and in accordance with CMS/NCCI and Priority Health billing guidance.
Examples of modifiers (not exhaustive)
- Modifier 59 — Distinct Procedure/Service.
- Modifier 90 — Reference (outside laboratory).
- Modifier 91 — Repeat clinical diagnostic laboratory test.
- Modifier QW — CLIA waived test(s).

Authorization or PreService Organization Determination requirements do not guarantee payment; authorization does not supersede coding, billing, or medical necessity requirements, and failure to follow billing or documentation rules may result in denial, recoupment, or claim rejection.

Referenced Diagnostic and Test Coding

Referenced diagnostic codesmixed

81513	Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, utilizing vaginal-fluid specimens, algorithm reported as a positive or negative result for bacterial vaginosis
81514	Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), and Lactobacillus species (L. crispatus and L. jensenii), utilizing vaginal-fluid specimens, algorithm reported as a positive or negative for high likelihood of bacterial vaginosis, includes separate detection of Trichomonas vaginalis and/or Candida species (C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis), Candida glabrata, Candida krusei, when reported
81515	Infectious disease, bacterial vaginosis and vaginitis, real-time PCR amplification of DNA markers for Atopobium vaginae, Atopobium species, Megasphaera type 1, and Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), utilizing vaginal-fluid specimens, algorithm reported as positive or negative for high likelihood of bacterial vaginosis, includes separate detection of Trichomonas vaginalis and Candida species (C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis), Candida glabrata/Candida krusei, when reported
82120	Amines, vaginal fluid, qualitative
83986	pH; body fluid, not otherwise specified
87070	Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
87149	Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed
87150	Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed
87210	Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)
87480	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique

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inv-03: Requirement for multiplex molecular testing

RequirementProvider must document why evaluation for more than one pathogen by molecular testing is necessary for clinical management or why single‑pathogen testing is not reasonable and necessary.

Documentation locationDocumentation must be recorded in the medical record and substantiate the procedure performed.

Clinical indicationProvider must state specific clinical indications for testing (e.g., clinical suspicion of a pathogen causing the member's condition).

Pre-Service Determinations and Authorization

Prior Authorization

Prior Authorization Required — PreService Organization Determination (PSOD)

For Medicare indications that do not meet the criteria of a National Coverage Determination (NCD), a local LCD, or a specific medical policy, the provider must obtain a PreService Organization Determination (PSOD) before the service is rendered. The PSOD documents medical necessity and helps determine coverage and payment. Click here for additional details on PSOD.

Applies when Medicare coverage criteria (NCD/LCD) or a specific Priority Health medical policy are not met
Authorization may be required depending on place of service and patient condition — see Place of Service guidance

Definitions

inv-05: Vaginitis

DefinitionInflammation of the vagina, often with discharge, itching, and discomfort; may result from disruption of the natural vaginal bacterial balance.

Common featuresSymptoms often include discharge, itching, and discomfort.

EtiologyCan be caused by infections or non‑infectious factors such as decreased estrogen levels and certain skin conditions.

inv-06: Infectious Vaginitis

DefinitionInfectious vaginitis is typically caused by infections such as bacterial vaginosis, yeast (candidiasis), or trichomoniasis.

Examples of pathogensBacterial vaginosis, Candida species (yeast), Trichomonas vaginalis.

Clinical relevanceIdentifying the specific pathogen guides appropriate diagnostic testing and treatment.

inv-07: Non-infectious Vaginitis

DefinitionNon‑infectious vaginitis includes atrophic vaginitis from decreased estrogen levels and irritant or allergic reactions to products (e.g., douches, soaps).

Common causesDecreased estrogen (postmenopausal atrophic changes), irritants, and allergens affecting the vulvovaginal area.

Distinguishing featuresMay present similarly to infectious causes but is not due to a pathogen; management differs accordingly.