Article - Billing and Coding: Influenza Diagnostic Tests (A54769)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextTo 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:Availableat the point of careYieldsa Flu A and Flu B result in < 30 minutesLess sensitive (50%-70%) and specific (90%-95%) compared to other methods and may require confirmation byreverse 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 manufacturers 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:UsesRT-PCR or other amplification methods to detect viral nucleic acidsResults available in < 24 hours (often in less than 2-4 hours)Detects from 1-2 to up to 20 respiratory pathogens from 1 specimenA 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 infectionResults available in 3-10 daysMissesopportunity for Oseltamivir (Tamiflu) treatment for positive patientsImmunofluorescence (IF) - Direct (DFA) or Indirect (IFA) Fluorescent Antibody Staining (antigen detection):Moderatesensitivity and high specificityResults available in approximately 2-4 hoursIf 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.