Influenza Rapid Diagnostic Tests (CPB 0476, reviewed 2026-07-24)

REQUIREMENTS: By August 7, 2026 (urgent - policy is 1 day old and already effective): - Billing team must update claim submission protocols to ensure influenza rapid test claims (CPT 87275, 87276, 87400, 87501, 87502, 87804, and multiplex codes 87634-87637) include medical necessity documentation confirming that results will inform clinical management, antiviral treatment decisions, or infection control measures. - Provider education staff must notify all clinicians that negative RIDT results (CPT 87275, 87276, 87400, 87804) NOW REQUIRE confirmatory molecular testing (CPT 87501, 87502) during high community influenza activity periods. Update EMR templates and encounter forms to reflect this requirement. - Billing software must be configured to flag claims for negative RIDT tests without corresponding molecular confirmatory test orders during flu season for manual review to prevent claim denials. - Front desk and laboratory staff must ensure specimen type and test type documentation is captured on orders, as different tests require different specimen types (throat, nasopharyngeal, or nasal). - Billing team must cross-reference appropriate ICD-10 codes (B34.9, J10.00-J11.89, R05.1-R05.9, R50.9, R06.02, R51.0-R51.9, R53.81) with test claims; claims without these or similar fever/respiratory symptom codes may be denied for lack of medical necessity. Failure to implement these changes will result in claim denials for influenza testing without proper medical necessity documentation and denial of confirmatory molecular tests when RIDTs are negative during high-activity periods.