Coding Advice from Experity RCM Team

We are finding that payers are wanting the symptom code of why they performed the lab, not a definitive diagnosis of Influenza (if positive). If there are no symptoms prompting the Influenza, at minimum, exposure should be documented but may not be paid diagnosis. 

 Though this is specific to Humana, we utilize it for other payers. We also use R09.81 (nasal congestion) even though it’s not listed as payable for Humana, other payers have paid on it. 

We are currently seeing that CPT 87633 – Respiratory panels covering more than five pathogens not covered due to lack of clinical justification.  Medicare and most Medicaid plans typically consider respiratory panel covering more than five pathogens as not medically reasonable and necessary, therefore non-covered. LCD explicitly exclude CPT 87633 (and 87632) from coverage in outpatient settings.