Primary Care Coding Alert

Faced with numerous endorsements that you can report a nurse visit for interpreting tuberculosis test results, family physicians (FPs) who question the legitimacy of this billing method may lose $20 per visit without reason. So, gather the facts and let your FP decide.

Normally, physicians are the first to fight for every earned penny. Therefore, to hear them argue otherwise is an interesting occurrence. "But FPs' reservations about reporting a 99211 for a TB interpretation are twofold," says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.

The first concern comes from misconceptions regarding what the fees for the tuberculosis skin test include. "Many FPs have always understood or interpreted the TB skin test code to include the reading, so the idea of separately coding for that reading seems 'unnatural,'" Moore explains.

This misunderstanding is now, however, a thing of the past. "Payment for 86580 (Skin test; tuberculosis, intradermal) includes the administration of the test only," CMS staff stated in an e-mail to Moore clarifying the skin test code. When a provider sees a patient in a separate face-to-face encounter to have the results read, Medicare will pay for the interpretation of the test results with 99211 (Office or other outpatient visit for an established patient typically, 5 minutes are spent performing or supervising these services), according to CMS.

Separately billing 99211 is permissible because not all patients return to have the test results read. "Every patient is supposed to return to have the test area checked, but I doubt that all patients (especially those that see no skin changes) actually have it checked," says Susan O. Minchew, CPC, CHC, director of billing compliance for Emory Healthcare in Atlanta. CMS'e-mail concurs with this nonautomatic interpretation visit by stating, "Reading of the test results is generally performed 2-3 days following the intradermal test in the office." The agency recognizes that the reading is not always performed.

Reasons for not returning to the office vary. For instance, the patient may not return because his or her spouse is a nurse, the patient knows what a negative or positive result looks like, or he or she may simply forget about the visit, Moore says.Because the reading is not automatic, the interpretation is not included in the test fee and is thus separately billable. Consequently, FPs will have to consider whether they want to charge for this service.

Despite these reasons, billing 99211 for the interpretation is still sticky due to patient relations (PR) concerns because the nurse code may trigger a copayment. "Fees usually range from $5-$30, but not all managed-care companies require a copayment for a nurse visit," Minchew says.

Therefore, although coding for reading a TB skin test is technically correct, it may be politically incorrect with the patients, especially if they have to pay a copayment for the privilege, Moore says. "Consequently, some FPs may decide that it's in the best interest of PR not to charge 99211 for reading a TB test."

Faced with financial pressures, your FP may lean toward acceptable coding, rather than PR concerns. If this is the case, you first should inject some protection into your practice.

Before your FPstarts collecting the reading fee on a regular basis, Minchew offers some advice. You should first contact managed-care payers for their approval, she recommends. In addition, include specific wording in your managed-care contracts that allows separate payment for the TB test reading. Having the policy in writing will protect your practice in case an auditor questions your billing method.

You should also ensure that your practice follows the basic rules on reporting 99211. To bill 99211 for a TB skin test reading, the clinician, such as the office nurse, should document why he or she saw the patient, results, and any relevant follow-up, Moore stresses. For example, the chart note may read: "Patient seen to read TB skin test administered on (date); test results neg." or "Patient seen to read TB skin test administered on (date); test results pos. INH (Isoniazid) prescribed for nine months."

You will need to check with individual payers for their policies concerning 99211 billing requirements. Some insurers may mandate that the physician see the patient. Others may allow a nurse or other ancillary staff to qualify for billing 99211.

Armed with these facts and recommendations, let your FP decide the course he or she would like to follow. These endorsements may encourage physicians to bill for the service based on the financial pressures they are faced with, Minchew says. "In many cases, patient relations will be far more valuable than the fee received for reading an occasional TB skin test," Moore says.You may also want to show your FP CMS' response, available at www.aafp.org/x16698.xml.

Note: Fees are based on unadjusted Medicare National Physician Fee Schedule for 99211 (0.56 relative value units) x $36.79 [conversion factor] = $20.60).