Pulmonology Coding Alert

Coding experts help us help you code TB skin tests and injection codes successfully every time

Before you report any tuberculosis (TB) related procedures (86580) look for documentation details on the patient's course of treatment after the initial skin test who interpreted the test results to the patient and the level of E/M services the pulmonologist provided because this will make or break your reimbursement.

Looking at these four frequently asked questions will determine whether you know how to report TB readings accurately. Write down your responses before looking to the correct answers below.

Question 1: Should I bill 99211 for tuberculosis (PPD) reading?

Question 2: We are trying to link the purified protein derivative (PPD) tuberculosis (TB) test to the correct ICD-9 code. We have been using V03.2 but we think that diagnosis is incorrect because V03.2 is a vaccination code. Which ICD-9 code should we report?

Question 3: Should I bill for an injection administration in addition to a tuberculosis (TB) skin test?

Question 4: When someone has a positive Mantoux (PPD) test and a negative chest x-ray and comes in for a visit to initiate INH (isonicotinic acid hydrazide called isoniazid) therapy what should we code? We code a moderate level office visit but what diagnosis should we use? We can't use tuberculosis because the chest x-ray was negative and if we use a V code we probably won't get paid.


Answer 1: You should report the initial purified protein derivative (PPD) tuberculosis test with 86580 (Skin test; tuberculosis intradermal).

Code 86580 does not cover any follow-up care. Therefore if the patient returns to the office to have the nurse evaluate the test's results you may report 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...typically 5 minutes are spent performing or supervising these services).

Most plans will usually pay for the nurse visit with the screening diagnosis. If the payer denies 99211 you may appeal the claim or charge the patient.

Remember: Don't forget to collect a copayment for the 99211 services the pulmonologist provides at the follow-up visit.

Answer 2: You should report V74.1 (Special screening examination for bacterial and spirochetal diseases; pulmonary tuberculosis) with 86580 (Skin test; tuberculosis intradermal) for pulmonary tuberculosis says Denae M. Merrill CPC coding specialist with NEM Pulmonary Associates in Saginaw Mich.

When a nurse or other individual in your office administers a PPD TB test she gives an inoculation screening test not a vaccination.

The TB screen test detects the disease's presence by inoculating the skin with the TB antigen. The TB screen doesn't vaccinate the person. Instead the screen is an inoculation to confer disease immunity. Therefore you should link the test code to the special screening V code instead of to the vaccination code Merrill advises.

In fact you will probably never use V03.2 (Need for prophylactic vaccination and inoculation against bacterial diseases; tuberculosis [BCG]).

The World Health Organization doesn't recommend that United States physicians administer the BCG vaccine. The inoculation isn't very effective and interferes with skin test screening. People who receive a TB vaccination can give a false-positive when screened for the disease.

Answer 3: No you should not report an administration code such as 90782 (Therapeutic prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) with 86580 (Skin test; tuberculosis intradermal) explains Lisa Center CPC quality coordinator with Freeman Health System in Joplin Mo.

The TB skin test includes the injection administration Center says.

 Answer 4: The best diagnosis code is 795.5 (Non-specific reaction to tuberculin skin test without active tuberculosis) and you should get paid if you report this code.

Unfortunately there is a slight chance that this could negatively affect a patient's future insurance with the tuberculosis label Center warns.

Even though the diagnosis is "without active tuberculosis " reporting 795.5 would get in the medical record database which all insurers have access to and some future carrier may well interpret this code as tuberculosis and restrict any coverage that may be related to tuberculosis. Health insurance obtained through employers would not have any such restrictions however.

And if the patient is treatment-free for a certain period of time the company - whether it's life or health insurance - will cover the service.

The bottom line: You should not be afraid to use the 795.5 diagnosis. This is the right code and avoiding it would be fraudulent Center says.

The only time you should avoid certain diagnoses is during the rule-out period. Also you have to document what the diagnosis is each time the patient comes in during the year of INH therapy. This documentation is important so that the pulmnologist can follow the therapy over time. You should also document a diagnosis for any orders for follow-up x-rays. Clinically a pulmonologist considers a patient with a positive skin test as seroconverted meaning the patient was exposed to TB and the immune system is or has been battling the infection.

The INH treatment assists the body in eliminating any remaining TB infection. All patients who have TB will have a positive PPD test but only a few patients with a positive PPD test have TB. If a PPD test is positive the diagnosis of TB is made by a chest x-ray sputum stains and cultures and by clinical symptoms.

Bonus: As a secondary diagnosis code you could also use V71.2 (Observation and evaluation for suspected conditions not found; observation for suspected tuberculosis).