ModifiedCommunity Care Independent Practice AssociationPolicy CP.MP.181

Polymerase Chain Reaction Respiratory Viral Panel Testing

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This policy establishes medical-necessity criteria and coding support for multiplex respiratory viral PCR testing, with separate requirements for panels detecting five or fewer versus six or more pathogens.

Policy Summary

PayerCommunity Care Independent Practice Association

PolicyPolymerase Chain Reaction Respiratory Viral Panel Testing

Policy CodePolicy CP.MP.181

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument the specific clinical indication, reason for panel testing, provider type or specialty, and place of service in the medical record.

SourceLink

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Medical Necessity Criteria

Panels with five or fewer pathogens

Respiratory viral panels testing for five pathogens or fewer are medically necessary when all of the following criteria are met.

All criteria A–G

A. Clinical indication: The member/enrollee is immunocompetent with presumed active infection or an infection-associated complication, which may include exacerbation of underlying disease, and identification of the causative organism is required for appropriate management; or the member/enrollee is immunocompromised, including due to HIV/AIDS, immunosuppressive medications, transplant-related immunosuppression, high-dose systemic corticosteroids, or an inherited immune-system disease. Atypical presentations may qualify, including in elderly patients and other special populations. In an immunocompromised member/enrollee, testing may be performed once as part of a pre-transplant evaluation regardless of symptoms.
B–G. Testing, performance, and documentation requirements
- B. Management impact: Testing results will affect clinical management in a manner demonstrated in peer-reviewed published literature to improve outcomes.
- C. Intended use and population: Testing is performed according to the intended use of the test and in the intended population for which the test was developed and validated.
- D. Targeted testing: Targeted testing is not appropriate because it would not provide sufficient information for appropriate clinical management.
- E. Minimum pathogens: The panel includes at least the minimum pathogens required for clinical decision-making for its intended use that can reasonably be detected by the test.
- F. Test performance: The registered test demonstrates equivalent or superior analytical validity and clinical validity to established standard-of-care methods, such as culture or pathogen-specific PCR, for the majority of targets included on the panel.
- G. Medical-record documentation: The medical record clearly states the specific clinical indication, including clinical suspicion of a pathogen as the cause of the medical condition; the specific reasons for performing panel testing; and the provider type or specialty and place of service.

Panels with six or more pathogens

Respiratory viral panels testing for six pathogens or more are medically necessary when the Section I criteria are met and at least one qualifying circumstance applies.

Section I plus a qualifying circumstance

Qualifying circumstance
- Severe underlying respiratory pathology: Examples include severe asthma, chronic obstructive pulmonary disease, cystic fibrosis, pulmonary fibrosis, or radiation therapy to the lung.

Supporting diagnosis codes

For applicable services, the billed CPT code and diagnosis coding must meet the policy’s required linkage.

Diagnosis-code linkage: The billed service uses a CPT code from Table 2 and is billed with a diagnosis code from the applicable supporting diagnosis tables, including the required Table 4 diagnosis-code relationship identified in the policy.

Covered Clinical Indications

Presumed active respiratory infection or infection-associated complication

Testing may be medically necessary when the clinical presentation and management plan support identification of a respiratory pathogen.

Presumed active infection or complication

Presentation: The presentation may be typical or atypical, including an atypical presentation in an elderly patient or other special population.

Immunocompromised member/enrollee with suspected infection or atypical presentation

Testing may be medically necessary for an immunocompromised member/enrollee with suspected infection or an atypical presentation.

Immunocompromised clinical indication: The member/enrollee is immunocompromised, including due to HIV/AIDS, chemotherapy, biologics, transplant-related immunosuppressive drugs, high-dose systemic corticosteroids, or an inherited immune-system disease, and has suspected infection or an atypical clinical presentation; or testing is performed once as part of a pre-transplant evaluation regardless of symptoms.

Coding and Billing Support

Respiratory viral panel size

Panel size5 pathogens or fewer

Respiratory viral panel size

Panel size6 pathogens or more

CPT codes supporting medical necessity in any place of service, without diagnosis code requirementsCPTCovered

87631

Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.

CPT and proprietary codes supporting medical necessity when billed with listed place-of-service or diagnosis codesmixedCovered

0115U	Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets, amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected.
0202U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
0223U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
0225U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected.
87632	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets.
87633	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets.

Place-of-service codes supporting medical necessity for codes in Table 2Revenue

19	Off Campus-Outpatient Hospital.
21	Inpatient Hospital.
22	Outpatient Hospital (Observation).
23	Emergency Room-Hospital.

ICD-10-CM diagnosis codes supporting medical necessity for CPT codes in Table 2ICD-10Covered

A37.00	Whooping cough due to Bordetella pertussis without pneumonia.
A37.01	Whooping cough due to Bordetella pertussis with pneumonia.
A37.10	Whooping cough due to Bordetella parapertussis without pneumonia.
A37.11	Whooping cough due to Bordetella parapertussis with pneumonia.
A37.80	Whooping cough due to other Bordetella species without pneumonia.
A37.81	Whooping cough due to other Bordetella species with pneumonia.
A37.90	Whooping cough, unspecified species without pneumonia.
A37.91	Whooping cough, unspecified species with pneumonia.
A41.81	Sepsis due to Enterococcus.
A41.89	Other specified sepsis.

1–10 of 21

1/3

Additional ICD-10-CM diagnosis codes supporting medical necessity for CPT codes in Table 2ICD-10Covered

J09.X1	Influenza due to identified novel influenza A virus with pneumonia.
J09.X2	Influenza due to identified novel influenza A virus with other respiratory manifestations.
J09.X3	Influenza due to identified novel influenza A virus with gastrointestinal manifestations.
J09.X9	Influenza due to identified novel influenza A virus with other manifestations.
J10.01	Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia.
J10.08	Influenza due to other identified influenza virus with other specified pneumonia.
J10.1	Influenza due to other identified influenza virus with other respiratory manifestations.
J10.2	Influenza due to other identified influenza virus with gastrointestinal manifestations.
J10.81	Influenza due to other identified influenza virus with encephalopathy.
J10.82	Influenza due to other identified influenza virus with myocarditis.

1–10 of 37

1/4

ICD-10 Diagnosis Codes Supporting Medical NecessityICD-10

J10.89	Influenza due to other identified influenza virus with other manifestations
J11.08	Influenza due to unidentified influenza virus with specified pneumonia
J11.1	Influenza due to unidentified influenza virus with other respiratory manifestations
J11.2	Influenza due to unidentified influenza virus with gastrointestinal manifestations
J11.81	Influenza due to unidentified influenza virus with encephalopathy
J11.82	Influenza due to unidentified influenza virus with myocarditis
J11.83	Influenza due to unidentified influenza virus with otitis media
J11.89	Influenza due to unidentified influenza virus with other manifestations
J12.0	Adenoviral pneumonia
J12.1	Respiratory syncytial virus pneumonia

1–10 of 81

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Table 5: ICD-10 Diagnosis Codes that Support Medical Necessity for CPT Codes in Table 2 when Billed with a Diagnosis Code in Table 4ICD-10

B20	Human immunodeficiency virus [HIV] disease
C46.0	Kaposi's sarcoma of skin
C46.1	Kaposi's sarcoma of soft tissue
C46.2	Kaposi's sarcoma of palate
C46.3	Kaposi's sarcoma of lymph nodes
C46.4	Kaposi's sarcoma of gastrointestinal sites
C46.50	Kaposi's sarcoma of unspecified lung
C46.51	Kaposi's sarcoma of right lung
C46.52	Kaposi's sarcoma of left lung
C46.7	Kaposi's sarcoma of other sites

1–10 of 125

1/13

ICD-10 diagnosis codes referencedICD-10

J84.89	Other specified interstitial pulmonary diseases
O98.711	Human immunodeficiency virus [HIV] disease complicating pregnancy, first trimester
O98.712	Human immunodeficiency virus [HIV] disease complicating pregnancy, second trimester
O98.713	Human immunodeficiency virus [HIV] disease complicating pregnancy, third trimester
T80.82XS	Complication of immune effector cellular therapy, sequela
Z51.11	Encounter for antineoplastic chemotherapy
Z92.850	Personal history of Chimeric Antigen Receptor T-cell therapy
Z92.858	Personal history of other cellular therapy
Z92.86	Personal history of gene therapy
Z94.0	Kidney transplant status

1–10 of 21

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CPT and proprietary laboratory codes mentioned in revision historyCPT

87632	Moved to the table of medically necessary codes when billed with applicable Place of Service codes
87633	Moved to the table of medically necessary codes when billed with applicable Place of Service codes
0098U	Added as medically necessary when billed with applicable Place of Service codes; later deleted in April 2021
0099U	Added as medically necessary when billed with applicable Place of Service codes; later deleted in April 2021
0100U	Added as medically necessary when billed with applicable Place of Service codes; later deleted in April 2021
0115U	Added as medically necessary when billed with applicable Place of Service codes
0202U	Added to CPT table 2 in June 2023
0223U	Added to CPT table 2 in June 2023
0225U	Added to CPT table 2 in June 2023

Documentation and Coverage Risk

Documentation Required

Document the clinical indication and testing rationale

The medical record must clearly state the specific clinical indication for testing, including clinical suspicion of a pathogen as the cause of the medical condition, the specific reasons for performing panel testing, and the provider type or specialty and place of service.

Denial Risk

Failure to meet medical-necessity criteria may result in denial

Coverage may be denied when medical-necessity requirements are not met, including the qualifying clinical indication, expected impact on clinical management, intended use and validated population, appropriateness of targeted testing, minimum pathogens needed for clinical decision-making, or test performance. For panels testing six or more pathogens, the Section I criteria must also be met along with a qualifying circumstance: care of critically ill individuals, immunocompromised status, or severe established respiratory pathology in an immunocompetent member when antibiotic treatment may be indicated under established guidelines.

Policy Background

Respiratory viral panel (RVP) PCR testing is a single molecular test that detects viral genetic material—RNA or DNA—from multiple respiratory viruses. Testing commonly uses a nasal, nasopharyngeal, or oropharyngeal swab. Because respiratory viral infections may present with nonspecific symptoms, timely identification can support appropriate antiviral use, infection-control decisions, and reduction of unnecessary antibiotic treatment; however, multiplex testing is most useful when the result is expected to affect patient management.

Key Definitions

Respiratory viral panel (RVP)

Test formatA single test that may detect RNA or DNA from multiple types of respiratory viruses

Specimen sourcesNasal, nasopharyngeal, or oropharyngeal swab

Testing methodPolymerase chain reaction (PCR)

Immunocompromised

DefinitionA person with a weakened immune system

Infections and conditionsHuman immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), or inherited diseases affecting the immune system, such as congenital immunoglobulin deficiencies

Medications and treatment

Frequency and Utilization Limits

Frequency limit

Respiratory viral panel frequencyOnce as part of a pre-transplant evaluation

Symptom requirementTesting may be performed regardless of the presence of symptoms