ModifiedWellCarePolicy N/A

INFECTIOUS DISEASE: RESPIRATORY LAB TESTING — Coding Implications

Defines clinical guidance citations and coding implications for laboratory testing of respiratory infections (including SARS-CoV-2, influenza, RSV, multiplex respiratory panels) and Group A Streptococcus diagnostics; intended for providers and billing/coding staff contracting with WellCare in the described jurisdiction.

Policy Summary

PayerWellCare

PolicyInfectious Disease: Respiratory Lab Testing — Coding Implications

Policy CodePolicy N/A

Change TypeCPT table updatedcode 0373U removed

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed CPT/HCPCS codes for billing and confirm code descriptions match the updated CPT code table before claim submission.

SourceLink

POLICY UPDATE CHANGES

Added 'Lab' to policy title.

Removed CPT and ICD-10 codes from policy reference table and moved CPT codes into a dedicated CPT code table under 'coding implications'.

Updated CPT code table — corrected code descriptions and removed code 0373U.

Updated CPT code table - corrected to change code descriptions and removed code 0373U.

Added 'Lab' to policy title and moved CPT/ICD references into a CPT code table; coding implications section was moved.

~80+CPT/HCPCS/PLA/NDC codes listed

IDSA 2020Referenced guideline (bacterial panels)

0225U,0240U,0241UCPT/HCPCS codes referenced

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical Coverage Criteria and Guidance

Clinical guidance references

Clinical guideline recommendations referenced (informational):

Bacterial NAAT guidance: Bacterial NAATs are most useful when patients have new or worsening lung infiltrates, are moderately to severely ill, have received empiric antibiotics before obtaining cultures, and/or there is concern for multidrug-resistant bacteria or a polymicrobial infection.

IDSA 2020

Influenza serology guidance: Serologic testing for the diagnosis of acute influenza should not be used because results from a single serum specimen cannot be reliably interpreted.

IDSA 2018

Group A Streptococcus (GAS) testing guidance: Swab the throat and test for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture; in children a negative RADT should be backed up by a throat culture. Clinical features alone do not reliably discriminate GAS from viral pharyngitis except when overt viral features are present.

IDSA 2012; AAFP note on age 3–14 years as suggestive

Anti-streptococcal antibody titers guidance: Anti-streptococcal antibody titers (eg, ASO, anti-DNase B) are not recommended for routine diagnosis of acute pharyngitis because they indicate past infection and may not peak until 3–8 weeks after acute infection.

IDSA 2012

The Infectious Diseases Society of America (IDSA) guidance states that serologic testing should not be used to diagnose acute influenza A or B, because results from a single serum specimen cannot be reliably interpreted. This guidance is informational for clinicians and coding staff and indicates that antibody/serology assays are not appropriate for acute diagnostic use for seasonal influenza.

Operationally, the CPT code table in this policy has been updated: CPT code 0373U was removed during the recent CPT table correction and reorganization. Providers and billing staff should reference the updated CPT code table when selecting codes for claims.

IDSA guidance indicates that anti-streptococcal antibody titers (e.g., ASO, anti-DNase B) are not useful for the routine diagnosis of acute Group A Streptococcal pharyngitis because antibody levels may not peak until weeks after infection and can remain elevated thereafter. Similarly, IDSA advises that serologic testing for influenza is not reliable for acute diagnosis when based on a single serum specimen. These recommendations emphasize using direct detection methods (RADT, culture, or molecular tests) for acute diagnostic decisions rather than antibody titers or single-sample serology.

Coding Implications and Code Tables

Antibody/serology CPT codesCPT

86060	Antistreptolysin 0; titer.
86328	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]).
86408	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) (coronavirus disease [COVID-19]); screen.
86409	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) (coronavirus disease [COVID-19]); titer.
86413	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) antibody, quantitative.
86710	Antibody; influenza virus

Culture and organism identification CPT codesCPT

86769	Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
87040	Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate).
87070	Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates.
87071	Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool.
87073	Culture, bacterial; quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool.
87075	Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates.
87076	Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate.
87077	Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate.
87081	Culture, presumptive, pathogenic organisms, screening only.
87084	Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart.

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Antigen detection and typing CPT codesCPT

87118	Culture, mycobacterial, definitive identification, each isolate.
87140	Culture, typing; immunofluorescent method, each antiserum.
87143	Culture, typing; gas liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method.
87147	Culture, typing; immunologic method, other than immunofluorescence (eg, agglutination grouping), per antiserum.
87158	Culture, typing; other methods.
87275	Infectious agent antigen detection by immunofluorescent technique; influenza B virus.
87276	Infectious agent antigen detection by immunofluorescent technique; influenza A virus.
87400	Infectious agent antigen detection by immunoassay technique; Influenza, A or B, each.
87420	Infectious agent antigen detection by immunoassay technique; respiratory syncytial virus.
87426	Infectious agent antigen detection by immunoassay technique; SARS coronavirus (eg, SARS-CoV, SARS-CoV-2).

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Nucleic acid detection, multiplex respiratory panels, PLA and HCPCS U-codesmixed

87480	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique.
87481	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique.
87482	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification.
87485	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique.
87486	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique.
87487	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification.
87498	Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed.
87500	Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique.
87501	Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype.
87502	Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, multiplex RT and amplified probe technique, first 2 types or sub-types.

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Covered CPT/HCPCS CodesmixedCovered

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.
0240U	Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected.
0241U	Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected.
U0001	CDC Test.
U0002	Non-CDC Viral identification test, amplified probe.
U0003	High throughput Viral identification test, amplified probe.
U0004	High throughput Viral identification test, other than amplified probe.
U0005	Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2

Multiplex respiratory target counts

CPT 87631Respiratory virus multiplex RT and amplified probe technique — 3-5 targets.

CPT 87632Respiratory virus multiplex RT and amplified probe technique — 6-11 targets.

CPT 87633Respiratory virus multiplex RT and amplified probe technique — 12-25 targets.

U0005 turnaround time

Operational requirementU0005 testing for SARS-CoV-2 (amplified probe, high throughput) must be completed within 2 calendar days from date of specimen collection.

Related HCPCS codes

Provider Actions, Billing Guidance, and Risk Notices

Prior Authorization

This policy does not specify a prior authorization requirement. Providers should confirm PA rules with the member's benefit plan as needed.

Note

Coverage Not Guaranteed by Code Listing

Inclusion or exclusion of CPT codes in this policy is informational only and does not guarantee reimbursement. Coverage determinations are based on the member’s benefit plan and medical necessity.

Documentation Required

Coding Guidance and Documentation

Providers must use up-to-date coding guidance and the current CPT descriptions when submitting claims. Reference the latest AMA CPT resources and payer billing instructions to ensure accurate code selection and claim documentation.

Background and Scope

IDSA guidance on bacterial respiratory infection testing recommends that bacterial nucleic acid amplification tests (NAATs) are most useful in specific clinical scenarios — for patients with new or worsening lung infiltrates, moderate to severe illness, prior empiric antibiotics before cultures, or when there is concern for multidrug-resistant or polymicrobial infection. This policy’s scope focuses on laboratory testing and coding implications for respiratory pathogens (viral and bacterial) and Group A Streptococcus, providing informational clinical context for testing pathways and aligning coding guidance with those clinical recommendations.

Definitions and Testing Notes

Bacterial NAAT — clinical utility scenarios

Clinical utilityBacterial nucleic acid amplification tests (NAATs) are most useful when patients have new or worsening lung infiltrates.

SeverityMost useful when patients are moderately to severely ill.

Prior antibioticsUseful when patients received empiric antibiotics before obtaining cultures, which may reduce culture yield.

Resistance/polymicrobial concernIndicated when there is concern for multidrug-resistant bacteria or a polymicrobial infection.

Serologic testing for influenza — guidance

RecommendationIDSA does not recommend serologic testing for diagnosis of acute influenza.

Policy Revisions and Change Log

2024-03coding_updateLatest

Updated CPT code table — corrected code descriptions and removed CPT code 0373U.

2024-02title_and_structure_change

Added 'Lab' to the policy title and moved CPT/ICD-10 references into a dedicated CPT code table under 'coding implications'.

2023-11policy_development