Pediatric Coding Alert

Question: Our provider wants to start performing influenza testing in our office. Can you explain the difference between the different CPT^® codes? And how should we bill when testing for strains A and B?

Oklahoma Subscriber

Answer: Which test you bill depends entirely on the method of testing that your pediatrician decides to use. And there are a lot of them.

However, many of these are lab tests, which you would not typically do in-house. Only 87502 (Infectious agent detection by nucleic acid [DNA or RNA]; influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types) with its add-on +87503 (... each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure) or the most-used rapid test, 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; Influenza), are typically performed in a primary care setting.

Because they are simple tests which have little risk of error, the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) have given them special dispensation to be performed in a laboratory that is not subject to routine inspection.

To perform them, you will need to obtain a Clinical Laboratory Improvement Amendments (CLIA) waiver from the Centers for Medicare & Medicaid Services (CMS) by going to https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/How_to_Apply_for_a_CLIA_Certificate_International_Laboratories.html.

Then, once you are enrolled in the program, all you need to perform these and hundreds of other CLIA-waived tests is to pay certificate fees to the program biennially and follow any instructions provided by the test manufacturer. Additionally, for billing purposes, you will append modifier QW (Clia waived test) to the appropriate CPT^® code.

Finally, should you choose to perform 87804, note that you will have to run two separate tests, one each for the A & B influenza strains, which you will indicate by using modifier 59 (Distinct Procedural Service) even if you only use one kit to perform both tests. So, you would report 87804-QW and 87804-59-QW. You will only have to use 87502-QW once for both strains, however, if your provider uses that particular test.