Laboratory Medicine Update

November, 2022. This special edition content provided by Dr. Melinda Poulter. The Lab Medicine Update is a collaboration between the UVA Medical Laboratories and the UVA Clinical Laboratory Stewardship Subcommittee. Feedback on the LMU? Contact Jim Harrison (james.harrison@virginia.edu).

What respiratory testing options are available from the lab for COVID-19, RSV and Influenza this respiratory viral season? ↑

ED/Inpatients

• COVID-19 (SARS-CoV-2) stand-alone PCR: 3 hour turnaround time
• RSV, FluA/B, COVID-19 (SARS-CoV-2) ‘4-plex’ PCR: 3 hour turnaround time

Outpatients

• COVID-19 (SARS-CoV-2) stand-alone PCR: 12-24 hour turnaround time in most cases
• RSV, FluA/B, COVID-19 (SARS-CoV-2) 4-plex PCR: 12-24 hour turnaround time in most cases
• Point of Care Influenza A&B antigen tests may be available in some ambulatory settings
• RSV antigen testing is currently unavailable

Additional options (all settings)

• COVID-19 (SARS-CoV-2) stand-alone PCR: 12-24 hour turnaround time in most cases
• RSV, FluA/B, COVID-19 (SARS-CoV-2) 4-plex PCR: 12-24 hour turnaround time in most cases
• Point of Care Influenza A&B antigen tests may be available in some ambulatory settings
• RSV antigen testing is currently unavailable
• Respiratory Pathogens Panel (upper respiratory specimens)
  • 4-hour turnaround time for ED/Inpatients in most cases
  • 6-12 hour turnaround time for outpatient samples in most cases
• Respiratory Pathogens Panel (lower respiratory specimens)
  • 24-36 hour turnaround time in most cases for all locations
• The use of the Respiratory Pathogen Panel is strongly discouraged in ambulatory settings
  • Often results in high out of pocket expense for patient due to poor/no reimbursement
  • The 4-Plex test is often sufficient to meet needs in the ambulatory setting
  • May be appropriate for patients who are immunocompromised patients or have underlying pulmonary disease

What organisms and specimen types are included for each of these tests? ↑

COVID-19 (SARS-CoV-2) stand-alone PCR

• Acceptable Specimens:
  • Nasopharyngeal swab: Mini-tip submitted in approved viral transport medium
  • Throat swab: Large swab submitted in approved viral transport medium
  • Mid-Turbinate swab: Large swab in approved viral transport medium
  • Bronchoalveolar lavage: 1mL minimum in sterile leak-proof container (not available as a rapid test)
• Includes: SARS-CoV-2 (COVID-19) only

RSV, FluA/B, COVID-19 (SARS-CoV-2) ‘4-plex’ PCR

• Acceptable Specimens:
  • Nasopharyngeal swab: Mini-tip submitted in approved viral transport medium
  • Bronchoalveolar lavage: 1mL minimum in sterile leak-proof container (not available as a rapid test)
• Includes: RSV, FluA/B, COVID-19 (SARS-CoV-2)

Respiratory Pathogens Panel (upper respiratory specimens) with 4 hour turnaround time

• Acceptable Specimens:
  • Nasopharyngeal swab: Mini-tip submitted in approved viral transport medium
  • Throat swab: Large swab submitted in approved viral transport medium
• Includes: Influenza A with subtyping, Influenza B, Respiratory Syncytial Viruses A&B, COVID-19 (SARS-CoV-2), Parainfluenza 1,2,3,4, Rhinovirus/Enterovirus, Metapneumovirus, Adenovirus, Coronavirus (non-COVID strains), Chlamydia pneumoniae, and Mycoplasma pneumoniae

Respiratory Pathogens Panel (lower respiratory specimens) with 24 hour turnaround time

• Acceptable specimens:
  • Sputum: 1 mL minimum submitted in sterile leak-proof container
  • Bronchial lavage/wash: 1mL minimum in sterile leak-proof container
• Includes: Influenza A with subtyping, Influenza B, Respiratory Syncytial Viruses A&B, Parainfluenza 1,2,3,4, Metapneumovirus, Rhinovirus/Enterovirus, Adenovirus, Coronavirus (non-COVID strains), Chlamydia pneumoniae, and Mycoplasma pneumoniae. Does NOT include COVID-19 (SARS-CoV-2)

What is the best way to test for Influenza in outpatients? ↑

Here is a comparison of Influenza and COVID antigen versus PCR testing for patients with Influenza-like illness (e.g. fever, cough, sore throat):

• Point Of Care FluA/B antigen tests or COVID-19 (SARS-Cov-2) antigen test
  • Advantages: Simple to perform in an office setting, rapid results available within 15-30 minutes, may be more affordable
  • Disadvantages: Good sensitivity, but false negative results can occur especially as the community prevalence increases; test as early in the illness course as possible to reduce false negative results (ideally less than 4 days from illness onset)
• 4-plex PCR test (RSV/ FluA/FluB/SARS-CoV-2)
  • Advantages: Very high sensitivity so false negative results are less likely
  • Disadvantages: May be more expensive (see financial information below)

How does the timing of testing work? ↑

Routine testing for COVID-19 (SARS-CoV-2) by PCR and Flu/RSV/COVID-19 (SARS-CoV-2) 4-plex PCR on upper respiratory specimens (nasopharyngeal swabs) is performed on systems around the clock.

• Samples from the ED or inpatient units, and those for hospital admission are automatically triaged to rapid testing with a 3 hour turnaround time
• Samples from Employee Health and those for Pre-Procedural or Facility Discharge testing are prioritized with a 6-12 hour turnaround time
  • Contact Clinical Laboratory Customer Service at 4-LABS (4-5227) for rapid testing required for same-day Facility Discharge cases
• During high volume periods, expect 24 hour turnaround times for all other testing, unless prioritization is approved by the Hospital Epidemiologist on call (PIC 9204)

How does sputum/BAL testing work? ↑

• Lower respiratory specimens for the Respiratory Pathogens Panel are only performed once daily, typically starting in the morning around 5AM
• Bronchoalveolar Lavage (BAL) samples for COVID-19 PCR or Flu/RSV/COVID-19 4-Plex PCR are performed on systems around the clock, and results are usually available in 12-24 hours

What PPE is required for obtaining samples? ↑

Recommended PPE guidance details can be found here.

What is the charge for the different respiratory testing options? ↑

*Generally patients will not pay these amounts for the tests. However, most insurance companies will only reimburse for the Respiratory Pathogens Panel if the patient is immunocompromised or has underlying pulmonary disease. Ordering this test could result in high out of pocket costs for ambulatory patients.

What would a patient with insurance pay for the RSV, FluA&B, COVID-19 (SARS-CoV-2) 4-plex PCR? ↑

• They would pay their portion of the test’s allowable charge (this is the negotiated rate between UVA and the payor)
• A patient’s selected plan benefit might call for them to pay 20% (co-insurance) of that allowable charge
  • Their plan may have a copay for the lab (i.e. $10 per test) or a patient may have a deductible they have not yet met
• The payor communicates these amounts to us when the claim is sent, and the patient is billed accordingly
• For these tests thus far we have not yet seen any patient cost sharing
  • This means there have not been co-insurance or co-pay amounts assessed to patients

Some examples of allowables for RSV, FluA&B, COVID-19 (SARS-CoV-2) 4-Plex PCR test are below:

Do charges change if the test is ordered in the Emergency Department and/or my patient is admitted? ↑

• If the patient is seen in the ED and discharged the charge is the same and is billed like any other outpatient service
• If the patient is seen in the ED and admitted to the hospital for an inpatient stay, the charge is the same, but the bill is included as part of the inpatient stay. This may be paid as part of a DRG under the patient’s insurance, or paid according to the self-pay guidelines below if the patient is uninsured.

What would a patient with no insurance or who has qualified for financial assistance pay for the RSV, FluA&B, COVID-19 (SARS-CoV-2) 4-plex PCR test? ↑

Here are examples of the self-pay out-of-pocket costs for the 4-Plex test:

These percentages (excluding 'Uninsured') would also apply to any patient that has Financial Assistance/Charity as secondary to a Commercial or Governmental coverage.