CurrentBlue Cross Blue Shield - TexasPolicy CPCPLAB033

Diagnostic Testing of Influenza

Defines Blue Cross Blue Shield of Texas reimbursement criteria for laboratory testing for influenza, including which test types are reimbursable and restrictions for symptomatic vs asymptomatic individuals; applies to providers submitting claims to BCBSTX.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyDiagnostic Testing of Influenza

Policy CodePolicy CPCPLAB033

Change TypeRevised (coding/billing clarifications and ordering)

Effective DateSep 25, 2025

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved code sets; claims are subject to claim review and code edits.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information #1 was revised for clarity and a new Note 2 was added specifying billing units when both influenza A and B are detected by certain CPT codes.

Note 1 (typical influenza signs and symptoms) was revised to align with CDC guidance.

Procedure codes were re-ordered numerically and code 87631 was removed.

References list was updated following a literature review.

1single reimbursable rapid test allowed for symptomatic individuals

0viral culture reimbursable

0influenza testing reimbursable for asymptomatic individuals

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Influenza Testing Reimbursement Criteria

Influenza testing reimbursement rules

Covered when the following conditions are met:

ALL of the following

ONE of
- One single rapid flu test (either a point-of-care rapid nucleic acid amplification test [NAAT] or a rapid antigen test).
- One single traditional NAAT.

Viral culture testing for influenza is not reimbursable.

Asymptomatic individuals: influenza testing (examples include rapid antigen tests, rapid NAAT/RT-PCR tests, traditional RT-PCR tests, and viral culture) is not reimbursable.

Serology testing for influenza is not reimbursable.

Billing rule: When a single 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.

CPT Codes and Billing Units

Referenced CPT codes with special billing unitsCPTCovered

87400	CPT code referenced for tests that may detect influenza A and/or B; when both detected up to two units may be billed
87501	CPT code referenced for tests that may detect influenza A and/or B; when both detected up to two units may be billed
87804	CPT code referenced for tests that may detect influenza A and/or B; when both detected up to two units may be billed

Units allowed when both A and B detected

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

Applicable CPT codes87400, 87501, 87804 (tests that may detect influenza A and/or B)

ScopeApplies when both influenza A and B are detected by a single test at one visit.

LimitMaximum of two units billed per visit for the specified CPTs when both A and B are detected.

Documentation and Claim Submission Requirements

Documentation Required

Documentation, coding and claim submission requirements

Providers must submit accurate documentation of services performed and code claims using valid HIPAA-approved code sets and 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/editing software logic; upon request providers should submit additional documentation.

Use code combinations from HIPAA-approved code sets (e.g., CPT, HCPCS, ICD-10-CM/PCS, NDC) and follow industry coding guides (Uniform Billing, AMA CPT resources, CMS NCCI manuals).
Claims are subject to claim review and code edits; providers may be asked to provide additional documentation to support the claim.
Review applicable plan documents and provider contracts when determining coverage, as plan documents or contracts govern in case of conflict.

Typical Influenza Signs and Symptoms

Typical influenza signs and symptoms

Fever or chillsFever or feeling feverish/chills

Respiratory symptomsCough; sore throat; runny or stuffy nose

Systemic symptomsHeadaches; muscle or body aches; fatigue

GastrointestinalVomiting and/or diarrhea (more common in children)