CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO33

Diagnostic Testing of Influenza

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Defines reimbursement and laboratory coverage criteria for influenza diagnostic tests for Blue Cross Blue Shield of Texas members, including which tests are reimbursable for symptomatic and asymptomatic individuals and related coding guidance.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyDiagnostic Testing of Influenza

Policy CodePolicy CPCPLABO33

Change TypeRevisedRemovedClarified

Effective DateSep 25, 2025

Last ReviewSep 25, 2025

Next Review Date

Key ActionFor symptomatic individuals, bill one reimbursable test per encounter: either one traditional NAAT or one rapid flu test; when a single test detects both influenza A and B (CPT 87400, 87501, 87804), up to two units may be billed.

SourceLink

POLICY UPDATE CHANGES

Revised reimbursement information to clarify that for symptomatic individuals one, but not both, of a single traditional NAAT or one single rapid flu test may be reimbursable and added reference to a new Note 2 about billing multiple units when tests detect both influenza A and B.

Revised the Note with signs and symptoms of influenza to align with CDC guidance.

Removed CPT code 87631 from the procedure code list.

Codes placed in numerical order; references updated following literature review.

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CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO33

Diagnostic Testing of Influenza

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Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyDiagnostic Testing of Influenza

Policy CodePolicy CPCPLABO33

Change TypeRevisedRemovedClarified

Effective DateSep 25, 2025

Last ReviewSep 25, 2025

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Revised the Note with signs and symptoms of influenza to align with CDC guidance.

Removed CPT code 87631 from the procedure code list.

Codes placed in numerical order; references updated following literature review.

Coverage Criteria for Influenza Diagnostic Testing

Reimbursable and non-reimbursable influenza testing

Covered when ALL of the following are met

Symptomatic testing reimbursement: For symptomatic individuals (typical influenza signs and symptoms), one, but not both, of the following may be reimbursable: either one single traditional NAAT OR one single rapid flu test (point-of-care rapid NAAT or rapid antigen test).one test per symptomatic encounter

See Note 1 for symptom list and Note 2 for billing when both A and B are detected.

Asymptomatic testing: For asymptomatic individuals, influenza testing (rapid antigen, rapid NAAT/RT-PCR, traditional RT-PCR) is not reimbursable.none reimbursable

Claims for asymptomatic screening are not covered.

Viral culture and serology: Viral culture testing and serology testing for influenza are not reimbursable.none reimbursable

Explicit exclusions for viral culture and serology.

Billing for tests detecting both influenza A and B

Multiple-detection billing: When a single influenza test represented by CPT codes 87400, 87501, or 87804 detects both influenza A and influenza B, up to two units may be billed at a single visit.up to 2 units per visit

Applies to listed CPT codes only.

Viral culture and serology testing for influenza are explicitly excluded from reimbursement under this policy. The policy states that viral culture testing for influenza is not reimbursable and that serology testing for influenza is not reimbursable.

Influenza diagnostic testing performed in asymptomatic individuals is considered not reimbursable / not medically necessary under this policy. The policy specifies that testing modalities including rapid antigen tests, rapid NAAT or RT-PCR, traditional RT-PCR, and viral culture for asymptomatic persons are not reimbursable.

Covered Indications

Symptomatic individuals exhibiting typical influenza signs and symptoms (fever, cough, sore throat, headache, muscle/body aches, nasal symptoms, fatigue, vomiting/diarrhea in children).

Symptomatic individuals exhibiting typical influenza signs and symptoms (fever or feeling feverish/chills; cough; sore throat; headache; muscle or body aches; stuffy or runny nose; fatigue; vomiting and/or diarrhea — more common in children).

These signs and symptoms define the symptomatic population referenced in reimbursement criteria.

Coding and Billing Guidance

Representative reimbursable test CPT codes referenced for multi-detection billing guidanceCPTCovered

87400	Infectious agent detection by nucleic acid (DNA or RNA); influenza, each type or subtype
87501	Infectious agent detection by nucleic acid (DNA or RNA); influenza B
87804	Infectious agent antigen detection by immunoassay, influenza A and B

Removed codesCPTNot Covered

87631

Removed from code list

inv-07: Units billable when both A and B detected — up to 2 units

Billing ruleWhen a single influenza test represented by CPT codes 87400, 87501, or 87804 detects both influenza A and influenza B, up to two units may be billed at a single visit.

Applicable CPT codes87400, 87501, 87804 (only these codes apply to the multi-detection billing guidance)

Limit per visitUp to 2 units billed at a single visit when both A and B are detected by the listed test.

ScopeApplies when a single test detects both influenza A and B; does not expand billing for separate tests.

Frequency Limits and Reimbursement per Encounter

inv-15: one single traditional NAAT or one single rapid flu test — One test reimbursable per symptomatic encounter

Reimbursable frequency per symptomatic encounterOne test reimbursable per symptomatic encounter: either one single traditional NAAT OR one single rapid flu test.

Test types consideredTraditional NAAT OR point-of-care rapid NAAT OR rapid antigen test (rapid flu test).

Mutual exclusivityOne, but not both options may be reimbursed for the same symptomatic encounter.

Asymptomatic testing noteInfluenza testing for asymptomatic individuals is not reimbursable under this policy.

Provider Actions and Documentation Requirements

Prior Authorization

Review plan- and product-specific prior authorization and coverage rules

Some lab management reimbursement criteria vary by product; providers must review member plan documents, provider contracts, certificates, benefit booklets, and other coverage documents to determine whether prior authorization or product-specific requirements apply for influenza testing services. When plan documents conflict with this policy, the plan document governs.

Note

Follow plan rules and single-test reimbursement rule for symptomatic encounters

Providers must follow plan documents and provider contracts and submit services using industry-standard coding systems and guidelines; ensure claims reflect the single reimbursable test rule for symptomatic encounters (one traditional NAAT OR one rapid flu test).

Ordering Requirements

Note

Verify product-specific ordering/prior authorization and submit accurate documentation

Review plan-specific ordering and prior authorization requirements before ordering tests and ensure all required documentation is submitted with the claim to support medical necessity and proper adjudication.

Verify product-specific ordering/prior authorization rules in member plan documents.
Include accurate test codes and supporting clinical documentation with the claim.

Definitions

inv-13: Influenza symptoms — Typical Influenza Signs and Symptoms

Core symptom listFever or feeling feverish/chills; Cough; Sore throat; Headaches; Muscle or body aches; Stuffy or runny nose; Fatigue; Vomiting and/or diarrhea (more common in children).

Population noteGastrointestinal symptoms (vomiting/diarrhea) are noted to be more common in children than adults.

UsageThese typical signs and symptoms define symptomatic individuals for whom one test may be reimbursable.

Background

Influenza typically presents with respiratory and systemic symptoms such as fever or feeling feverish/chills, cough, sore throat, headache, and muscle/body aches, and may include nasal symptoms, fatigue, and in children gastrointestinal symptoms like vomiting or diarrhea. Diagnostic testing is relevant when patients are symptomatic because it can inform antiviral treatment and clinical management. The policy limits reimbursement to testing performed for symptomatic individuals exhibiting these typical signs and symptoms.

Not Covered

Not covered: viral culture testing and serology testing for influenza, and any influenza diagnostic testing performed for asymptomatic individuals (this includes rapid antigen tests, rapid NAAT/RT-PCR, and traditional RT-PCR). Claims for these tests and contexts are not reimbursable and may be denied.