Summary & Overview
CPT 87804: Influenza Antigen Detection by Immunoassay
CPT code 87804 is a widely used billing code for the detection of influenza antigens through immunoassay with direct optical observation. This test is a cornerstone in the rapid diagnosis of influenza, enabling clinicians to quickly identify and manage cases during peak flu seasons. The code is applicable to CLIA-waived in-office testing, making it accessible in outpatient settings and supporting efficient patient care.
Major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, recognize and reimburse for services billed under CPT code 87804. The publication provides a comprehensive overview of payer coverage, clinical context, and relevant policy updates. Readers will gain insights into typical sites of service, associated clinical specialties, and the role of this code in the broader landscape of infectious disease diagnostics. Benchmarks and trends related to influenza testing are also discussed, offering valuable information for stakeholders in laboratory medicine, clinical operations, and healthcare policy.
This summary serves as a resource for understanding the significance of CPT code 87804 in national healthcare delivery, highlighting its impact on patient care, payer coverage, and laboratory operations.
CPT Code Overview
CPT code 87804 is used for the detection of infectious agent antigens by immunoassay with direct optical (visual) observation, specifically for influenza. This procedure falls under the Pathology and Laboratory Procedures (Microbiology) service type. The typical site of service for this test is an office setting (POS 11), where CLIA-waived in-office testing is performed. This code is commonly utilized during influenza season to rapidly identify the presence of influenza antigens, supporting timely clinical decision-making.
Clinical & Coding Specifications
Clinical Context
A patient presents to a family medicine or internal medicine office with symptoms such as fever, cough, sore throat, and body aches during influenza season. The clinician suspects influenza and performs a rapid influenza antigen test using a CLIA-waived immunoassay with direct optical observation. The test is conducted in the office setting (Place of Service 11), and results are available during the visit to guide clinical management. The workflow involves specimen collection (typically a nasal or throat swab), immediate testing, and visual interpretation of the results by the provider or laboratory staff.
Coding Specifications
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Modifiers:
- Modifier
QW: Indicates that the test is CLIA-waived and performed in a setting approved for such tests. - Modifier
59: Used when reporting distinct procedural services, such as separate results for influenza A and B when performed on the same day.
- Modifier
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Provider Taxonomies:
| Taxonomy Code | Specialty Name |
|---|---|
291U00000X | Clinical Medical Laboratory |
207Q00000X | Family Medicine Physician |
207R00000X | Internal Medicine Physician |
- Specialties Represented:
- Clinical Medical Laboratory: Laboratory professionals performing diagnostic tests.
- Family Medicine Physician: Primary care providers managing acute and chronic illnesses.
- Internal Medicine Physician: Providers specializing in adult medicine and acute care.
Related Diagnoses
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J10.1- Influenza with other respiratory manifestations, seasonal influenza virus identified- Relevant when the patient has respiratory symptoms and the influenza virus is confirmed by testing.
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J11.1- Influenza with other respiratory manifestations, virus not identified- Used when the patient has respiratory symptoms suggestive of influenza, but the virus is not confirmed by laboratory testing.
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J09.X2- Influenza due to identified novel influenza A virus with other respiratory manifestations- Applies when a novel influenza A virus is detected and the patient has respiratory symptoms.
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J10.0- Influenza with pneumonia, seasonal influenza virus identified- Used when influenza is confirmed and the patient also has pneumonia.
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J11.0- Influenza with pneumonia, virus not identified- Used when pneumonia is present and influenza is suspected but not confirmed by testing.
Related CPT Codes
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87636- Infectious Agent Antigen Detection (multiplex) SARS–CoV‑2, influenza A, and influenza B- Used for multiplex testing when SARS-CoV-2 and both influenza A and B are detected in a single assay. This code is an alternative to
87804when broader respiratory pathogen testing is needed.
- Used for multiplex testing when SARS-CoV-2 and both influenza A and B are detected in a single assay. This code is an alternative to
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87807- Infectious Agent Antigen Detection; respiratory syncytial virus (RSV)- Used for rapid antigen detection of RSV, often performed alongside influenza testing in patients with respiratory symptoms, especially in pediatric populations.
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Clinical Workflow Relation:
87636may be used instead of87804when testing for multiple pathogens simultaneously.87807is commonly used together with87804to differentiate between influenza and RSV in symptomatic patients.
National Reimbursement Benchmarks
National mean rates for CPT code 87804 among commercial payers are led by Aetna at $19.33, while Blue Cross Blue Shield and UnitedHealth Group are lower at $15.91 and $17.14, respectively. The BUCA average is $17.14, which is slightly below Aetna and close to Cigna and UnitedHealth Group. Medicare rates are not available in the input for comparison.
Rate dispersion varies significantly across payers. UnitedHealth Group shows the tightest range, with a difference of $2.00 between the 75th and 25th percentiles, indicating less variability in contracted rates. Cigna displays the widest spread, with a $12.83 difference, reflecting greater variability in reimbursement. Aetna and BUCA also show moderate dispersion, while Blue Cross Blue Shield is relatively tight at $4.67.
The table and chart below present the full breakdown of national benchmarks for CPT code 87804 by payer, including mean rates and percentile values.
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