Healthcare Fraud Shield’s Latest Article: Don’t Get Sick from Flu Codes

27 Aug
Influenza, more commonly referred to as the “flu” is a contagious respiratory virus that can have a wide range of symptoms. In mild cases, a patient may exhibit symptoms such as fever, fatigue, body aches and sore throat. In the most extreme cases, especially in the very young or elderly, influenza can be fatal.
In the United States, although influenza viruses circulate year-round, “flu season” occurs in the fall and winter, often peaking between December and February, but can extend well beyond that[1].

Influenza Testing

There are several different tests to detect influenza. The two main types you may see most often are DNA/RNA based tests or immunoassay tests. Though both can provide relatively quick results, the immunoassay tests, also known as Rapid Influenza Diagnostic Tests (RDIT) are usually faster and can typically provide results while the patient waits. The DNA/RNA tests typically take longer and may prevent results during the same visit. The DNA/RNA tests often carry a higher associated cost.

How is it billed?

  • 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[2]
  • 87804: Infectious agent antigen detection byimmunoassay with direct optical observation; Influenza[3]
What to Look For

Although testing has value under the correct clinical circumstances, according to the CDC, testing is not needed for all patients with signs and symptoms of influenza to make antiviral treatment decisions. Once influenza activity has been documented in the community or geographic area, a clinical diagnosis of influenza can be made for outpatients with signs and symptoms consistent with suspected influenza, especially during periods of peak influenza activity in the community[4].

To detect potential fraud, waste or abuse, the below analytic behaviors could be worth additional review:
  • When were tests performed? Did they occur during flu season?
  • Did patients receive BOTH DNA/RNA and RDIT tests within the same time frame? What order?
  • Did many/most patients receive testing?
  • Did most patients receive the DNA/RNA? What was the clinical rationale?
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