87254
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Follow the device manufacturer’s package insert for specimen collection, handling, and test performance as required for test validity and billing.
- Document timing of symptom onset and specimen collection (ideally within 3–4 days of onset) in the medical record.
- When a rapid antigen test is performed and then confirmed using PCR, report the confirmatory test with modifier -59 as appropriate for billing.
- When a CLIA-waived test is performed, report the waived test with the -QW modifier for billing.
Key Coverage Criteria
- Perform molecular influenza testing (eg, RT-PCR) for hospitalized patients with suspected influenza.
- Point-of-care providers should consider influenza testing prior to prescribing antibiotics or antiviral treatment when needed to avoid antibiotic overuse and resistance.
- Use rapid influenza diagnostic tests (RIDTs) that meet FDA sensitivity expectations (≥80% vs RT-PCR) and have high specificity when selecting a rapid diagnostic test.
- Collect respiratory tract specimens for influenza testing as early in illness as possible, preferably within 3–4 days of symptom onset.
- Consider targeted molecular methods (eg, multiplex RT-PCR) to detect influenza and other respiratory pathogens from a single specimen when broader pathogen detection is clinically useful.
- Send respiratory specimens for RT-PCR to confirm RIDT results when community influenza activity is low and RIDT is positive.
3 Active Policies
A54769 — Billing and Coding: Influenza Diagnostic Tests
A58817 — Billing and Coding: Influenza Diagnostic Tests
A59055 — Billing and Coding: Influenza Diagnostic Tests
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.