Local Coverage Article Billing and Coding

Billing and Coding: Influenza Diagnostic Tests

A59056

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A59056
Article Title
Billing and Coding: Influenza Diagnostic Tests
Article Type
Billing and Coding
Original Effective Date
03/09/2022
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2022 American Dental Association. All rights reserved.

Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

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.

Coding Information

CPT/HCPCS Codes

Group 1

(10 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
87252 VIRUS ISOLATION; TISSUE CULTURE INOCULATION, OBSERVATION, AND PRESUMPTIVE IDENTIFICATION BY CYTOPATHIC EFFECT
87253 VIRUS ISOLATION; TISSUE CULTURE, ADDITIONAL STUDIES OR DEFINITIVE IDENTIFICATION (EG, HEMABSORPTION, NEUTRALIZATION, IMMUNOFLUORESCENCE STAIN), EACH ISOLATE
87254 VIRUS ISOLATION; CENTRIFUGE ENHANCED (SHELL VIAL) TECHNIQUE, INCLUDES IDENTIFICATION WITH IMMUNOFLUORESCENCE STAIN, EACH VIRUS
87275 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA B VIRUS
87276 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA A VIRUS
87400 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH
87501 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, INCLUDES REVERSE TRANSCRIPTION, WHEN PERFORMED, AND AMPLIFIED PROBE TECHNIQUE, EACH TYPE OR SUBTYPE
87502 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES
87503 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, EACH ADDITIONAL INFLUENZA VIRUS TYPE OR SUB-TYPE BEYOND 2 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
87804 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; INFLUENZA

CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
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

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A


N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Revision History Information

N/A

Associated Documents

Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
03/23/2022 03/09/2022 - N/A Currently in Effect You are here

Keywords

N/A