LCD Reference Article Billing and Coding Article

Billing and Coding: Influenza Diagnostic Tests

A59055

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Source Article ID
N/A
Article ID
A59055
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Influenza Diagnostic Tests
Article Type
Billing and Coding
Original Effective Date
03/09/2022
Revision Effective Date
03/09/2022
Revision Ending Date
N/A
Retirement Date
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CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA) §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim

Article Guidance

Article Text

To avoid the overuse of antibiotics and the potential risk of antibiotic resistance, point of care providers should consider testing patients prior to prescribing treatment for a bacterial or influenza infection. Influenza testing (using molecular methods) is recommended for hospitalized patients with suspected influenza. However, testing is not needed for all outpatients with signs and symptoms consistent with influenza before making antiviral treatment decisions, particularly once influenza activity has been documented in the community. The following summary provides a list of the main available types of diagnostics tests:

Rapid Antigen Tests:

  • Available at the point of care
  • Yields a Flu A and Flu B result in < 30 minutes
  • Less sensitive (50%-70%) and specific (90%-95%) compared to other methods and may require confirmation by reverse transcription-polymerase chain reaction (RT-PCR) or viral culture. Note: the Food and Drug Administration (FDA) now requires that all Rapid influenza diagnostic tests (RIDTs) achieve 80% or higher sensitivity compared with RT-PCR.
  • Centers for Disease Control and Prevention (CDC) recommendations:
    • Use rapid diagnostic tests with high sensitivity and specificity.
    • Collect respiratory tract specimens as early in the illness as possible (within 3-4 days of illness onset).
    • Follow manufacturer’s instructions, including handling of respiratory specimens, as described in the device package insert.
    • Consider sending respiratory specimens (from symptomatic patients) for RT-PCR to confirm results of RIDTs, especially in the following situations:
      • When community influenza activity is low and the rapid diagnostic test result is positive.
      • When community influenza activity is high and the rapid diagnostic test result is negative.

Contact your local or state health department for information about influenza activity.

      • A patient has had recent close exposure (this does NOT include eating cooked meat) to pigs or birds (including poultry) or other animals, and there is concern for infection with a novel influenza A virus.

Targeted Molecular Methods:

  • Uses RT-PCR or other amplification methods to detect viral nucleic acids
  • Results available in < 24 hours (often in less than 2-4 hours)
  • Detects from 1-2 to up to 20 respiratory pathogens from 1 specimen
  • A positive result (on testing of an upper respiratory tract specimen) in a person who recently received intranasal administration of live attenuated influenza virus vaccine (LAIV) may indicate detection of vaccine virus.

Viral Culture:

  • Confirms present active infection
  • Results available in 3-10 days
  • Misses opportunity for Oseltamivir (Tamiflu) treatment for positive patients

Immunofluorescence (IF) - Direct (DFA) or Indirect (IFA) Fluorescent Antibody Staining (antigen detection):

  • Moderate sensitivity and high specificity
  • Results available in approximately 2-4 hours

If a rapid antigen test is performed and then confirmed using PCR, the second test may require the -59 modifier.

If a CLIA-waived test is performed, the -QW modifier should be reported for the waived test.

Reference: Centers for Disease Control and Prevention. Information for Clinicians on Rapid Diagnostic Testing for Influenza. Accessed 4/27/21.

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CPT/HCPCS Modifiers

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Group 1 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.
QW CLIA WAIVED TEST
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ICD-10-CM Codes that Support Medical Necessity

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Revision History Information

Revision History Date Revision History Number Revision History Explanation
03/09/2022 R1

Updated to indicate this article is not an LCD Reference Article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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Updated On Effective Dates Status
11/22/2023 03/09/2022 - N/A Currently in Effect You are here
03/23/2022 03/09/2022 - N/A Superseded View

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