Billing and Coding Article

Billing and Coding: Influenza Diagnostic Tests

A59055

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Noridian Healthcare Solutions, LLC	A and B MAC	01111 - MAC A	J - E	California - Entire State
Noridian Healthcare Solutions, LLC	A and B MAC	01112 - MAC B	J - E	California - Northern
Noridian Healthcare Solutions, LLC	A and B MAC	01182 - MAC B	J - E	California - Southern
Noridian Healthcare Solutions, LLC	A and B MAC	01211 - MAC A	J - E	American Samoa Guam Hawaii Northern Mariana Islands
Noridian Healthcare Solutions, LLC	A and B MAC	01212 - MAC B	J - E	American Samoa Guam Hawaii Northern Mariana Islands
Noridian Healthcare Solutions, LLC	A and B MAC	01311 - MAC A	J - E	Nevada
Noridian Healthcare Solutions, LLC	A and B MAC	01312 - MAC B	J - E	Nevada
Noridian Healthcare Solutions, LLC	A and B MAC	01911 - MAC A	J - E	American Samoa California - Entire State Guam Hawaii Nevada Northern Mariana Islands

Article Information

General Information

Article ID
A59055

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
N/A

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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.

Response To Comments

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1

Coding Information

Bill Type Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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(2 Codes)

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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

ICD-10-CM Codes that Support Medical Necessity

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

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Group 1 Codes

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ICD-10-PCS Codes

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Additional ICD-10 Information

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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.

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Revenue Codes

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Other Coding Information

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

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.

Associated Documents

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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Billing and Coding: Influenza Diagnostic Tests

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