Billing and Coding: Influenza Diagnostic Tests (A59055)
Contractor Name
Contract Number
States
Noridian Healthcare Solutions, LLC
01111 - A and B MAC
California - Entire State
01112 - A and B MAC
California - Northern
01182 - A and B MAC
California - Southern
01211 - A and B MAC
American Samoa
Guam
Hawaii
Northern Mariana Islands
01212 - A and B MAC
American Samoa
Guam
Hawaii
Northern Mariana Islands
01311 - A and B MAC
Nevada
01312 - A and B MAC
Nevada
01911 - A and B MAC
American Samoa
California - Entire State
Guam
Hawaii
Nevada
Northern Mariana Islands
Article Information
Article ID Number: A59055 Status: A-Approved
Article Title: Billing and Coding: Influenza Diagnostic Tests
Original Article Effective Date:
03/09/2022
Revision Effective Date:
01/01/2025
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.
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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
CPT/HCPCS Codes:
Group 1 Paragraph:
N/A
Group 1 CPT Codes:
0528U
LOWER RESPIRATORY TRACT INFECTIOUS AGENT DETECTION, 18 BACTERIA, 8 VIRUSES, AND 7 ANTIMICROBIAL-RESISTANCE GENES, AMPLIFIED PROBE TECHNIQUE, INCLUDING REVERSE TRANSCRIPTION FOR RNA TARGETS, EACH ANALYTE REPORTED AS DETECTED OR NOT DETECTED WITH SEMIQUANTITATIVE RESULTS FOR 15 BACTERIA
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
ICD-10 Codes That Are Covered
N/A
ICD-10 Codes That Are Not Covered
N/A
Revision History Information
Revision History Date
Revision History Number
Revision History Explanation
01/01/2025
R2
Revision Effective Date: 01/01/2025
CPT/HCPCS Codes Group 1:
Added: 0528U
01/02/2025: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
03/09/2022
R1
Updated to indicate this article is not an LCD Reference Article.