CurrentBlue Cross Blue Shield - TexasPolicy CPCPLAB033

Diagnostic Testing of Influenza

Reimbursement criteria for laboratory diagnostic testing of influenza for Blue Cross and Blue Shield of Texas members, governing which influenza tests are eligible for reimbursement and under what circumstances.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyDiagnostic Testing of Influenza

Policy CodePolicy CPCPLAB033

Change TypeNo material change

Effective DateJan 1, 2025

Next Review Date

Key ActionSubmit claims with accurate documentation and valid codes; providers may be requested to submit additional documentation for claim review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1single reimbursable test per symptomatic individual when influenza activity documented

2types of single reimbursable tests listed

4test categories not reimbursable

10procedure codes listed

Coverage Criteria for Influenza Diagnostic Testing

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Reimbursement criteria

Covered when ALL of the following are met:

ALL of the following

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

Exclusions

Viral culture testing for influenza is not reimbursable.
Influenza testing for asymptomatic individuals is not reimbursable (includes rapid antigen tests, rapid NAAT or RT-PCR tests, traditional RT-PCR tests, viral culture).
Serology testing for influenza is not reimbursable.

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

Procedure Codes and Reimbursement Limits

Example influenza diagnostic procedure codesCPT

87804	Influenza test code (example list from policy)
87400	Influenza test code (example list from policy)
87501	Influenza test code (example list from policy)
87502	Influenza test code (example list from policy)
87503	Influenza test code (example list from policy)
86710	Influenza test code (example list from policy)
87275	Influenza test code (example list from policy)
87276	Influenza test code (example list from policy)
87631	Influenza test code (example list from policy)
87254	Influenza test code (example list from policy)

Maximum reimbursable tests per symptomatic episode

Maximum reimbursable tests per symptomatic episodeOne single test (either one traditional NAAT OR one rapid flu test — either a point-of-care rapid NAAT or a rapid antigen test) when influenza activity is documented in the community; only one of these options may be reimbursed (not both).

Applicable triggerInfluenza activity must be documented in the community or geographic area to qualify for the single reimbursable test.

Excluded test typesViral culture and serology testing for influenza are not reimbursable.

Asymptomatic testing policyInfluenza testing for asymptomatic individuals (rapid antigen, rapid NAAT, RT‑PCR, traditional RT‑PCR, viral culture) is not reimbursable.

Submission, Documentation, and Billing Requirements

Documentation Required

Submission, coding, and documentation requirements

Submit claims with accurate, complete documentation and use valid, industry-standard codes when billing for influenza testing. Review applicable plan documents for product-specific lab management reimbursement requirements; providers may be requested to submit additional documentation for claim review.

Providers are expected to submit claims using valid code combinations from HIPAA‑approved code sets and to code according to industry standard coding guidelines.
Claims are subject to code edit protocols and may be reviewed against benefit coverage, provider contract language, medical policies, and coding software logic.
Providers are urged to review plan documents for eligible coverage for services rendered and may be asked to provide additional documentation upon request.

Key Definitions

Symptomatic (Typical Influenza Signs and Symptoms)

Definition of symptomatic individualFever (100.4°F or higher or feeling feverish/chills) AND one or more of the listed respiratory/systemic symptoms.

Typical signs and symptoms — respiratoryCough; sore throat; runny or stuffy nose; difficulty breathing or shortness of breath.

Typical signs and symptoms — systemicHeadaches and/or body aches; fatigue; fever or feeling feverish/chills (100.4°F or higher).