CPT Code Overview

CPT code 87636 is used for the detection of infectious agents by nucleic acid (DNA or RNA), specifically targeting severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2), which causes Coronavirus disease (COVID‑19), as well as influenza virus types A and B. This procedure utilizes a multiplex amplified probe technique, allowing simultaneous testing for multiple respiratory pathogens. The service falls under Pathology and Laboratory Procedures – Microbiology and is typically performed in a laboratory setting, such as a hospital or independent laboratory. This code is essential for rapid and accurate diagnosis of respiratory infections, supporting clinical decision-making and public health efforts.

Clinical Context

A patient presents to their healthcare provider with symptoms such as fever, cough, and sore throat during respiratory virus season. The provider orders a multiplex nucleic acid test to simultaneously detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza virus types A and B. The specimen is collected (typically a nasopharyngeal swab) and sent to a hospital or independent laboratory. The laboratory performs the test using an amplified probe technique, reporting results to the provider for clinical management. This workflow is common for patients with suspected COVID-19 or influenza, especially those with underlying immunodeficiency conditions.

Coding Specifications

• Modifier QW: Indicates that the test is CLIA-waived and can be performed in laboratories with a CLIA Certificate of Waiver.

• Provider Taxonomies:

• Specialties Represented:
  • Clinical Medical Laboratory: Laboratories performing diagnostic testing.
  • Pathology: Physicians specializing in laboratory medicine.
  • Family Medicine Physician: Providers ordering tests for primary care patients.

Related Diagnoses

• B97.29: Other coronavirus as the cause of diseases classified elsewhere

  • Relevant for patients suspected of COVID-19 or other coronavirus infections.

• D80.0: Hereditary hypogammaglobulinemia

  • Indicates a primary immunodeficiency, increasing risk for respiratory infections.

• D80.1: Nonfamilial hypogammaglobulinemia

  • Another immunodeficiency, relevant for patients with recurrent infections.

• D80.2: Selective deficiency of immunoglobulin A [IgA]

  • Patients with IgA deficiency are more susceptible to respiratory viruses.

• D80.3: Selective deficiency of immunoglobulin G [IgG] subclasses

  • IgG subclass deficiencies can predispose to viral infections.

• D80.4: Selective deficiency of immunoglobulin M [IgM]

  • IgM deficiency may increase risk for respiratory infections.

• D80.5: Immunodeficiency with increased immunoglobulin M [IgM]

  • Relevant for patients with abnormal immune responses.

• D80.6: Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia

  • Indicates atypical antibody profiles, relevant for infection risk.

• D80.8: Other immunodeficiencies with predominantly antibody defects

  • Covers additional antibody-related immunodeficiencies.

• D81.0: Severe combined immunodeficiency [SCID] with reticular dysgenesis

  • SCID patients are highly susceptible to viral infections.

• D81.1: Severe combined immunodeficiency [SCID] with low T- and B-cell numbers

  • Indicates profound immunodeficiency, relevant for testing.

• D81.2: Severe combined immunodeficiency [SCID] with low or normal B-cell numbers

  • SCID variant, relevant for infection risk.

• D81.31: Severe combined immunodeficiency due to adenosine deaminase deficiency

  • Specific SCID etiology, relevant for respiratory virus testing.

• D81.32: Adenosine deaminase 2 deficiency

  • Another immunodeficiency, increasing susceptibility to respiratory infections.

Related CPT Codes

• 87637: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique.

Relation to 87636:

• 87637 expands the multiplex panel to include respiratory syncytial virus (RSV) in addition to SARS-CoV-2 and influenza A/B.
• 87636 and 87637 are alternatives depending on whether RSV testing is clinically indicated.
• These codes are not typically billed together for the same specimen; one is selected based on the viruses being tested.

National mean rates for CPT code 87636 show that Aetna has the highest average reimbursement at $148.06, while UnitedHealth Group and Blue Cross Blue Shield are lower at $125.72 and $122.27, respectively. The BUCA (average commercial) mean rate stands at $132.55, which is notably higher than typical Medicare rates, though Medicare data is not available in the input for this code.

Rate dispersion varies significantly across payers. Aetna exhibits the tightest range between the 25th and 75th percentiles ($143.00 - $142.00 = $1.00), indicating minimal variation in contracted rates. In contrast, Cigna shows the widest spread ($169.00 - $75.00 = $94.00), reflecting substantial variability in reimbursement. Blue Cross Blue Shield and BUCA also display moderate dispersion, while UnitedHealth Group's range is $75.50.

The table and chart below present a detailed breakdown of national benchmarks for each payer.