CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB033

Diagnostic Testing of Influenza

Defines outpatient reimbursement criteria for influenza laboratory testing for Blue Cross Blue Shield New Mexico members, including which test types are reimbursable and when; applies to providers submitting claims for covered members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiagnostic Testing of Influenza

Policy CodePolicy CPCPLAB033

Change TypeRevised wording and reimbursement criteria

Effective DateSep 1, 2023

Next Review Date

Key ActionSubmit claims with accurate documentation and valid HIPAA-approved codes; claims are subject to review and plan documents govern when conflicts arise.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and literature review updated in the July 5, 2023 update.

Onesingle rapid flu test reimbursable per outpatient diagnostic encounter when influenza activity present

Onesingle traditional NAAT reimbursable per outpatient diagnostic encounter when influenza activity present

0viral culture reimbursable in outpatient setting

0influenza serology reimbursable under any circumstance

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procedure codes listed for influenza testing (not exhaustive)

Outpatient Influenza Testing Coverage

Outpatient testing criteria

Covered when ALL of the following are met:

ALL of the following

ONE, but NOT BOTH of the following may be reimbursable:
- One single rapid flu test (includes either a point-of-contact rapid nucleic acid amplification test [NAAT] or a rapid antigen test).
- One single traditional NAAT.

Viral culture testing for influenza in an outpatient setting is not reimbursable.

In asymptomatic patients, outpatient influenza testing (including rapid antigen flu tests, rapid NAAT or RT-PCR tests, traditional RT-PCR tests, and viral culture testing) is not reimbursable.

Serology testing for influenza is not reimbursable under any circumstance.

NOTE 1: Typical influenza signs and symptoms: Fever: a 100.4°F or higher temperature or feeling feverish/chills AND one or more of: cough; sore throat; headaches and/or body aches; difficulty breathing or shortness of breath; fatigue; runny or stuffy nose.

Procedure Codes and Allowable Tests

Listed influenza test codes (not exhaustive)CPT

87804
87400
87501
87502
87503
86710
87275
87276
87631
87254

Allowed tests per outpatient diagnostic encounter — one rapid flu test OR one traditional NAAT when influenza activity documented

Allowed tests per outpatient diagnostic encounterWhen influenza activity is documented in the community, one — but NOT both — of the following may be reimbursable: either one single rapid flu test (point-of-care rapid NAAT or rapid antigen) OR one single traditional NAAT (e.g., RT-PCR).

ContextApplies to patients presenting in the outpatient setting with signs and symptoms consistent with influenza (see Note 1 for symptom definition).

Limit per encounterOnly one test (either rapid or traditional NAAT) is eligible for reimbursement per outpatient diagnostic encounter when criteria met.

Documentation and Claim Submission Requirements

Documentation Required

Documentation and claim submission requirements

Providers must submit accurate documentation of services performed and submit claims using valid HIPAA‑approved code sets and appropriate code combinations. Claims are subject to code edit protocols and review against benefit coverage, provider contracts, medical policies, clinical payment and coding policies, and coding software logic; BCBSNM may request additional documentation. If a conflict exists between this policy and a plan document or provider contract, the plan document or provider contract will govern.

Use valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, DRG, etc.) and follow industry coding guidelines.
Claims are subject to code edit protocols and review; be prepared to provide additional documentation upon request.
Plan documents or applicable provider contracts govern in the event of a conflict with this policy.

Key Definitions

One single rapid flu test (includes point-of-contact rapid NAAT or rapid antigen test)

DefinitionOne single rapid flu test — includes either a point-of-contact rapid nucleic acid amplification test (NAAT) or a rapid antigen test.

SettingIntended for outpatient diagnostic encounters when influenza activity is documented and patient has compatible signs/symptoms.

LimitationsIf a rapid flu test is performed, a traditional NAAT for the same encounter is not reimbursable (ONE, but NOT BOTH).

Standard nucleic acid amplification test (RT-PCR or equivalent)

DefinitionStandard nucleic acid amplification test — traditional NAAT (e.g., RT-PCR or equivalent).

Reimbursement conditionMay be reimbursable as the single allowable test for an outpatient diagnostic encounter when influenza activity is documented and patient is symptomatic.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiagnostic Testing of Influenza

Policy CodePolicy CPCPLAB033

Change TypeRevised wording and reimbursement criteria

Effective DateSep 1, 2023

Next Review Date

Key ActionSubmit claims with accurate documentation and valid HIPAA-approved codes; claims are subject to review and plan documents govern when conflicts arise.

SourceLink

On This Page

Mutual exclusivityIf a traditional NAAT is reimbursed for the encounter, a rapid flu test is not reimbursable for that same encounter (ONE, but NOT BOTH).

Influenza testing in patients without signs or symptoms; not reimbursable

Policy stanceInfluenza testing in asymptomatic patients is not reimbursable — includes rapid antigen tests, rapid NAAT/RT-PCR, traditional RT-PCR, and viral culture.

ScopeApplies to outpatient testing of patients without signs or symptoms of influenza.

ImplicationClaims for influenza testing in asymptomatic individuals will not meet reimbursement criteria under this policy.

Not all-encompassing; inclusion does not guarantee coverage or reimbursement (procedure code list)

Not all-encompassing listThe procedure code list provided in the policy is not all-encompassing; inclusion of a code does not guarantee it is a covered service or eligible for reimbursement.

Provider actionProviders should not assume coverage solely because a code appears on the list; plan documents and reimbursement criteria govern final eligibility.

ExamplesProcedure codes are listed in the policy for reference but are explicitly stated as not exhaustive; review plan terms for coverage determinations.