B34.9 — Viral infection, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record documentation of clinical signs/symptoms consistent with influenza-like illness (examples listed in policy/background: fever, malaise, cough, myalgia, headache, shortness of breath).
- Documentation of the specific rapid test used (test name/manufacturer) and the test result (positive/negative) and date/time of specimen collection.
- Documentation of specimen type collected (throat, nasopharyngeal, nasal aspirate/swab/wash) and laboratory performing the test.
- If CPT code 87804 is billed, documentation that selection criteria were met (note: policy states 'covered if selection criteria are met' but does not list additional criteria; clinical indication/diagnosis codes from the provided ICD-10 list should be documented).
Key Coverage Criteria
- Tests to help distinguish influenza from other viral infections (and occasionally streptococcal pharyngitis) in patients with headache, muscle aches, fever, and/or cough when the clinical diagnosis is uncertain (especially in the absence of an epidemic).
- Rapid diagnostic tests that can be performed in an outpatient/physician office setting or in a moderately complex clinical laboratory (depending on the specific test's approval/requirements).
- Rapid diagnostic tests for viral influenza are considered medically necessary (examples cited: Directigen Flu A, Directigen Flu A+B, Flu OIA, Quickvue Influenza Test, Z Stat Flu).
- ICD-10 diagnoses covered if selection criteria are met: B34.9 (Viral infection, unspecified); J10.00 - J11.89 (Influenza due to other influenza virus); M79.10 - M79.18 (Myalgia); R05 (Cough); R50.9 (Fever, unspecified); R06.02 (Shortness of breath); R51 (Headache); R53.81 (Other malaise).
- Use of rapid diagnostic tests to assist in selecting appropriate antiviral therapy, avoiding inappropriate antibiotic therapy, and initiating measures to decrease spread of disease.
- CPT code 87804 (infectious agent antigen detection by immunoassay with direct optical observation; influenza) is covered if selection criteria are met.
1 Active Policy
AETNA-CPB-0476 — Influenza Rapid Diagnostic Tests
Related Codes
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