The Texas Medical Association is seeking clarification from Blue Cross and Blue Shield of Texas (BCBSTX) on its newest flu testing policy after learning the payer is denying certain claims for the diagnostic.
As of this writing, BCBSTX has not responded to requests by TMA’s Physician Payment Resource Center (PPRC). Meanwhile, payment specialists from the center offer guidance on avoiding and appealing flu-testing denials.
PPRC Director Carra Benson says physicians should look at BCBSTX’s flu testing policy, effective since Jan. 1, and document appropriately alongside the associated codes. BCBSTX included a list of code numbers related to the guidance – 87804, 87400, 87501, 87502, 87503, 86710, 87275, 87276, 87631, and 87254 – though the insurer cautioned this was “not an all-encompassing code list.”
Per BCBSTX’s guidance, payment eligibility is contingent on the tested patient exhibiting symptoms such as a fever of 100.4 F (38.0 C) or above, or feeling feverish or chills, plus at least one of six other symptoms:
- Headaches and/or body aches;
- Difficulty breathing or shortness of breath;
Charles Hu, MD, a Sugar Land pediatrician who reached out to PPRC, says the fever and symptom requirements impede payment for medical care.
“The issue is that when kids are exposed to flu and they have cold symptoms and they don’t yet have a fever, [BCBSTX is] going to reject [the claim],” he said.
The denials have come amid a rising number of flu-related emergency department visits, hospitalizations, and deaths, per the Texas Department of State Health Services’ (DSHS’) interactive dashboard monitoring respiratory illness.
DSHS is still enlisting physicians’ help in its enhanced flu surveillance, including monitoring for the H5N1 variant of the influenza A virus. TMA staff confirmed samples collected for DSHS are treated separately, and BCBSTX denials won’t affect DSHS processing or impart additional charges to physicians.
“Physicians using point-of-care testing for patients presenting with influenza-like illness can obtain an additional specimen to be sent to a public health laboratory for subtyping at no additional cost,” DSHS said in its request issued this past November.
Physicians who wish to participate in the state’s sample collection project should contact Carolyn Crisp, a Centers for Disease Control and Prevention career epidemiology field officer at DSHS.
Visit the PPRC page on the TMA website to request help with denied claims and check out its billing and coding tips for physicians.
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.