CPT Code Overview

CPT code 87428 is used to report the detection of infectious agent antigens for both severe acute respiratory syndrome coronavirus (such as SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B. This test utilizes immunoassay techniques, including enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), fluorescence immunoassay (FIA), or immunochemiluminometric assay (IMCA), to provide qualitative or semiquantitative results.

Service Type: Pathology and Laboratory Procedures – Microbiology Procedures

Typical Site of Service: Laboratory setting (POS 81) or Office (POS 11)

Clinical Context

A patient presents to a healthcare provider with symptoms of acute respiratory illness, such as fever, cough, and shortness of breath. The provider suspects infection with either severe acute respiratory syndrome coronavirus (SARS-CoV, SARS-CoV-2 {COVID-19}) or influenza virus types A or B. A specimen, typically a nasopharyngeal swab, is collected in the office or sent to a laboratory. The laboratory performs an immunoassay test using CPT code 87428 to qualitatively or semi-quantitatively detect antigens for both SARS-CoV-2 and influenza A/B. The results assist the provider in determining the cause of the patient's symptoms and guide further management.

Coding Specifications

• Modifier QW: Indicates that the test is CLIA-waived and can be performed in settings with a CLIA Certificate of Waiver, such as physician offices or certain laboratories.

• Provider Taxonomies:

• Typical Site of Service:
  • Laboratory setting (POS 81)
  • Office (POS 11)

Related Diagnoses

• B97.29: Other coronavirus as the cause of diseases classified elsewhere

  • Relevant for patients suspected of COVID-19 or other coronavirus infections.

• D80.0: Hereditary hypogammaglobulinemia

  • Indicates a primary immunodeficiency, increasing susceptibility to respiratory infections.

• D80.1: Nonfamilial hypogammaglobulinemia

  • Another immunodeficiency, relevant for patients with recurrent infections.

• D80.2: Selective deficiency of immunoglobulin A [IgA]

  • IgA deficiency predisposes to respiratory tract infections, justifying testing.

• D80.3: Selective deficiency of immunoglobulin G [IgG] subclasses

  • IgG subclass deficiency can lead to increased risk of viral infections.

• D80.4: Selective deficiency of immunoglobulin M [IgM]

  • IgM deficiency may result in poor response to infections, including viral.

• D80.5: Immunodeficiency with increased immunoglobulin M [IgM]

  • Associated with abnormal immune response, relevant for infection testing.

• D80.6: Antibody deficiency with near‑normal immunoglobulins or with hyperimmunoglobulinemia

  • Patients may have increased susceptibility to respiratory viruses.

• D80.8: Other immunodeficiencies with predominantly antibody defects

  • Broad category for antibody-related immunodeficiencies.

• D81.0: Severe combined immunodeficiency [SCID] with reticular dysgenesis

  • SCID patients are highly susceptible to viral infections.

• D81.1: Severe combined immunodeficiency [SCID] with low T‑ and B‑cell numbers

  • Profound immunodeficiency, relevant for infection testing.

• D81.2: Severe combined immunodeficiency [SCID] with low or normal B‑cell numbers

  • SCID variant, increased risk for viral infections.

• D81.31: Severe combined immunodeficiency due to adenosine deaminase deficiency

  • Specific SCID type, relevant for infection risk.

• D81.32: Adenosine deaminase 2 deficiency

  • Another immunodeficiency, justifying respiratory virus testing.

Related CPT Codes

• 87635: Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2

  • Used for molecular testing (PCR) to detect SARS-CoV-2 RNA. Often performed when antigen tests are negative or inconclusive, or for confirmatory testing.

• 87804: Infectious agent antigen detection by immunoassay with direct optical observation; Influenza

  • Used for rapid antigen testing for influenza A and B. May be used as an alternative or in conjunction with 87428 if only influenza is suspected.

• 87811: Infectious agent antigen detection by immunoassay with direct optical observation; SARS-CoV-2

  • Used for rapid antigen testing for SARS-CoV-2. May be used as an alternative or in conjunction with 87428 if only COVID-19 is suspected.

• 87426: Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative; SARS-CoV-2

  • Used for antigen detection of SARS-CoV-2 only. May be used as an alternative to 87428 when influenza testing is not required.

Clinical Workflow Relation:

• 87428 is used when both SARS-CoV-2 and influenza A/B need to be tested simultaneously.
• The other codes are used for single-agent testing or confirmatory purposes.

For CPT code 87428, the national mean rate for BUCA (average commercial) is $62.85, which is higher than the mean rate for Cigna ($44.99) and BCBS ($55.53), but lower than Aetna ($74.88). UnitedHealth Group's mean rate is $62.49, closely matching the BUCA average. Medicare data is not available in the input for comparison.

Rate dispersion, measured as the difference between the 75th and 25th percentiles, varies significantly across payers. Aetna shows the tightest range ($2.25), indicating minimal variation in rates. Cigna exhibits the widest dispersion ($46.00), reflecting substantial variability in reimbursement. Blue Cross Blue Shield and UnitedHealth Group also display moderate ranges of $20.20 and $30.50, respectively.

The table and chart below present a detailed breakdown of national mean rates and percentile values for each payer.