CPT CODE AND Description
86485 – Skin test; candida
86490 – Skin test; coccidioidomycosis – Average Fee amount $65 – $90
86580 – Skin test; tuberculosis, intradermal – Average Fee amount $7 – $10
ALL CPT required CLIA. Recently Medicare Excluded these CPTs from CLIA Edits
TB Testing – CPT 86580 / ICD9 V74.1
• Since the test is an inoculation screening test, rather than a vaccination, the test includes administering the skin test and you should not code separately for the administration.
• The Resource Based Relative Value System (RBRVS) does not include costs for a reading.
• Patients who do not show a response to the test may never return for a reading so this nurse “reading” cost is not included in the RVUs for 86580.
• If the patient does return for a reading, you may code 99211 for the nurse reading. Make sure to document appropriately
Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Bundling Update
UnitedHealthcare Community Plan has received additional clarification from Arizona Health Care Cost Containment System (AHCCCS) regarding Tuberculosis Testing services (86580) included in the EPSDT visit. The AHCCCS Medical Policy Manual, Chapter 400, Policy 430, contains language specifically related to lab testing:
Payment for laboratory services that are not separately billable and considered part of the payment made for the EPSDT visit include, but are not limited to: 99000, 36415, 36416, 36400, 36406, and 36410. In addition, payment for all laboratory services must be in accordance with limitations or exclusions specified in AHCCCS health plan contract with the providers1.
Since CPT 86580 falls under Pathology/Laboratory services and is not included in those codes listed above, services using CPT 86580 during the EPSDT visit should be billed and processed separately according to the AHCCCS provider contract.
UnitedHealthcare Community Plan will reflect these changes by March 24, 2015. Any claims previously denied or recovered prior to this correction being implemented will be adjusted to process appropriately according to this new guidance.
1. Currently, CPT Code 86485* – Skin test; Candida – is the code available for the cost of the CANDIN and materials used in the skin test. This code does not include possibly related procedures such as office visits, injection, reading, or patient consultation.
3. Submit reasonable and necessary charges in accordance with, along with the current CPT Code. (current CANDIN estimated price per test is $14.90**).
4. The insurance company may ask for a copy of the invoice for the purchase of CANDIN in order to confirm the price.
Services Bundled Example: If procedure code 80047 (PCTC IND of 9 ) or 86485 (PCTC IND of 3) is reported with a facility place of
service, the line item will deny.
Do you know how to code for a PPD/TB Skin Test? Proper coding for this test is quite simple. CPT 86580 is described as Skin Test; tuberculosis, intradermal and includes the administration of the test; therefore, do not attempt to bill any type of administration code in conjunction with CPT 86580. The appropriate diagnosis code for CPT 86580 is V74.1.
Generally, the nurse will administer the skin test and instruct the patient to return to the clinic for a reading a few days later. A nurse visit, CPT 99211 may be reported for the reading. The nurse must remember to document a proper nurse visit note (this is an E&M service)
• To be able to separate purchased vs. state supplied TST use the LU114 code for state supplied TST (report only) and the CPT code 86580 for purchased TST which can have a charge attached.
• If the client has private insurance only and a RN is the provider, you can use the 99211 E&M code. Other providers eligible to bill private insurance would use the appropriate E&M code for the level of service provided.
• When a client receives TB services (must be for a billable TB service) billed with an E&M code and is also seen by another health department provider on the same date of service for a separately identifiable medical condition, the health department may bill the appropriate E&M code, provided the diagnosis on the claim form indicates the separately identifiable medical condition and modifier 25 is deppended to the E & M code for the second visit.
TB treatment services
Performed by professional providers – office visits only The E/M codes 99201-99215 are for office visits only, and must be billed for professional providers such as physicians (or nursing staff under a physician’s supervision), Advanced Registered Nurse Practitioners (ARNPs), and Physician Assistants (PAs). Performed by professional providers – in client’s home, see home services.
Performed by nonprofessional providers – office visits and in client’s home Health departments billing for TB treatment services provided by nonprofessional providers in either the client’s home or in the office must bill using HCPCS code T1020 (personal care services). Do not bill the initial visit with a modifier. Follow-up visits must be billed using T1020 with modifier TS (follow-up services modifier). Use the appropriate ICD diagnosis code. See the agency’s Approved Diagnosis Codes by Program web page for Physician-Related Services/Health Care Professionals.
TB treatment services – performed by professional providers – in client’s home When billing for TB treatment services provided by professional providers in the client’s home, Health Departments may also bill CPT codes 99341 and 99347.
For TB treatment services performed by nonprofessional providers in client’s home, see TB treatment services for nonprofessional providers – office or client’s home
Targeted TB testing with interferon-gamma release assays
Targeted TB testing with interferon-gamma release assays may be considered medically necessary for clients age five and older for one of the following conditions:
• History of positive tuberculin skin test or previous treatment for TB disease
• History of vaccination with BCG (Bacille Calmette-Guerin)
• Recent immigrants (within 5 years) from countries that have a high prevalence of tuberculosis
• Residents and employees of high-risk congregate settings (homeless shelters, correctional facilities, substance abuse treatment facilities)
• Clients with an abnormal chest X-ray (CXR) consistent with old or active TB
• Clients undergoing evaluation or receiving TNF alpha antagonist treatment for rheumatoid arthritis, psoriatic arthritis, or inflammatory bowel disease
• Exposure less than two years before the evaluation
• Client agrees to remain compliant with treatment for latent tuberculosis infection if found to have a positive test
The tuberculin skin test is the preferred method of testing for children under the age of 5.
CPT Code Short Description 86480 Tb test cell immun measure 86481 Tb ag response t-cell susp Providers must follow the agency’s expedited prior authorization (EPA) process to receive payment for targeted TB testing. See EPA #870001325 in EPA Criteria Coding List.
Procedure Code Short Description
85032 Manual cell count each
85046 Reticyte/hgb concentrate
85049 Automated platelet count
85378 Fibrin degrade semiquant
85380 Fibrin degradj d-dimer
85384 Fibrinogen activity
85396 Clotting assay whole blood
85610 Prothrombin time
85730 Thromboplastin time partial
86308 Heterophile antibody screen
86367 Stem cells total count
86403 Particle agglut antbdy scrn
86880 Coombs test
86900 Blood typing ABO
86901 Blood typing rh (d)
86920 Compatibility test spin
86921 Compatibility test incubate
86922 Compatibility test antiglob
86923 Compatibility test electric
86971 Rbc pretx incubatj w/enzymes
87205 Smear gram stain
87210 Smear wet mount saline/ink
87281 Pneumocystis carinii ag if
87327 Cryptococcus neoform ag eia
87400 Influenza a/b ag eia
89051 Body fluid cell count
86367 Stem cells total count
86923 Compatibility test electric
88720 Bilirubin total transcut
88740 Transcutaneous carboxyhb
88741 Transcutaneous methb
Medicaid Guide – TUBERCULOSIS TESTING
Medicaid covers tuberculosis (TB) testing according to the AAP periodicity schedule, and upon the recognition of high risk factors. Coverage for the TB test includes any return visit to read the results of the TB test. A risk assessment must be completed at each well child visit. Mantoux testing is the preferred testing method. For assistance in determining high risk and testing, providers may refer to the AAP Red Book: Report of the Committee on Infectious Diseases, or contact the MDHHS Division of Communicable Diseases and/or the Division of Immunization.
TB nurse must bill TB services to Medicaid using T1002 and bill insurance using 99211 or T1002.
Sliding Fee Scale
1. A sliding fee scale can be attached to any program type, except STD and TB. Wherever a sliding fee scale is used, it must be consistently applied to all clients.
2. Not every program provided by LHDs must include a sliding fee scale (SFS). When a health department provides Adult Health Primary Care, Other services, Adult Dental services, it is their choice to apply a SFS (it is not required).
3. Health Department Dental Clinics are required to apply a SFS but it does not have to slide to zero.
4. Some DPH programs require that if their monies are used to provide a service, the fee for that service must slide to zero (e.g. Maternal Health, Family Planning, and Child Health).
Situations may exist where LHDs must bill services to Medicaid one way and private insurance (3rd party payers) a different way. Example: STD & TB – LHD may bill a T1002 to Medicaid and some private insurers. Some private insurers only accept 99211. Verify with each insurance carrier which codes they accept.
Medicaid will not reimburse separately for routine laboratory tests (Hemoglobin/Hematocrit and TB skin test) when performed during a Health Check early periodic screening visit. Other laboratory tests, including, but not limited to, blood lead screening, dyslipidemia screening, pregnancy testing, urinalysis, and sexually transmitted disease screening for sexually active youth, may be performed and billed when medically necessary. There must be documented symptoms or identified risks (based on history or physical exam) to bill for any additional labs (as part of a Periodic or Inter-periodic well child/preventive visit or as part of a sick/problem visit that may be provided on the same day as a preventive service). It must be supported with an appropriate ICD-10 code to explain why the service is being provided/requested, and the appropriate CPT code for the laboratory service must also be included.
TB nurse must bill TB services to Medicaid using T1002 and bill insurance using 99211 or T1002.
The following Physician or Advanced Practice Practitioners in a LHD setting are eligible to provide TB service:
* Physician (billed by E/M codes)
* Nurse Practitioner* (billed by E/M codes)
* Physician Assistants* (billed by E/M codes) Public Health Nurses* (billed by T1002 or reported by use of the appropriate LU code)
* Public health nurses (RNs) supervised by the public health nurse (RN) who is responsible for the TB Control Program and shall complete the Introduction to Tuberculosis Management course.
*Advanced Practice Practitioner
TB Disease or Contacts:
a. Per GS 130A-144 “the local health department shall provide, at no cost to the patient, the examination, and treatment for tuberculosis disease and infection…” As a result, TB services that deal with the examination and treatment of TB must be free or if billed to Medicaid or a third party payer the LHD must assure that the patient is not being billed for anything. This becomes problematic because most insurance companies have in their contract with the health department that they must collect co-pay from the insured patient. Medicaid does not require that a co-pay be collected due to this law. If you bill private insurance, then you would need to negotiate the copay issue with the insurance company.
b. The T1002 visit for TB clients is billed in units based on time recorded in client record by a Public Health (PH) Nurse under the guidance of a PH Nurse that has had the Introduction to TB course. The T1002 visits are for the monthly evaluation of clients on TB medication and not for DOT visits. (DOT is not a billable service, but DOT visits should be captured using LU121 or LU122). If your IT system does not accommodate the use of the LU Codes, please consult your vendor for further guidance. Time spent with eligible nurse seeing the client must be documented in the medical record. A good practice is to document time = units. Example: 30 minutes = 2 units. Remember: 1 unit = a full 15 minutes. Procedure code T1002 cannot be billed on the same day that a preventive medicine service is provided.
c. A maximum of 4 units per day may be billed per client. The time spent for each visit must be documented in the medical record. Time is defined as total time spent; for instance, 30 minutes’ time spent = 2 units. The documentation recording the TB service components provided should support the number of units billed.
d. Clients that are contacts to TB or are symptomatic cannot be charged for a TB skin test. Clients who need a TB skin test for reasons of employment or school may be charged if the health department uses purchased supply. (Reading the TB SKIN TEST is included as part of the total charge)
e. If the only service that a client comes in for is a skin test due to employment, school, etc., it should go under the TB program type. However, if the client comes in for another service like MH, CH, or FP and it is determined as a part of the history that they are at high risk for TB and need a skin test, then that TB SKIN TEST should go under the program that the client is in. The basic rule is that the TB SKIN TEST was then related to the program that brought the client in and is determined by the purpose of the visit.
f. To be able to separate purchased vs. state supplied TB SKIN TEST, use the LU114 code for state supplied TB SKIN TEST (report only) and the CPT code 86580 for purchased TB SKIN TEST, which can have a charge attached. If your vendor is unable to support the use of LU codes, you may need to work out a different mechanism for reporting state supplied TB SKIN TEST.
g. If the client has private insurance and an RN is providing monthly assessments, you can bill private insurance with the client’s permission using 99211 or T1002 provided the components to support the 99211 or T1002 are necessary and documented. Other Physician or Advanced Practice Practitioners eligible to bill private insurance would use the appropriate E/M code for the level of service, provided the components to support the E/M code are necessary and documented.
h. When a client receives a billable TB service (billed using an E/M code) and is also seen by the same health department Physician or Advanced Practice Practitioner on the same date of service for a separately identifiable medical condition, the health department may bill the appropriate E/M code, provided the diagnosis on the claim form indicates the separately identifiable medical condition and modifier 25 is appended to the E/M code that correlates to the primary reason for their visit to the health department. If the client is seen by a different health department Physician or Advanced Practice Practitioner on the same date of service …… no 25 modifiers is needed.
TB Skin Test (TST) and Interferon Gamma Release Assays (IGRA’s) for Employment, College or other non-mandated reasons
a. Clients who need a TST or IGRA for reasons of employment or school may be charged if the health department uses purchased supply. (Reading the TB skin test is included as part of the total charge.) It is preferable to use symptom and risk screening questionnaires in lieu of placing a skin test for low risk individuals and to place the skin test or obtain an Interferon Gamma Release Assay (IGRA) if the person responds yes to any of the questions. IGRA’s are preferred in this situation.
b. TST’s and IGRA’s can be provided as a flat fee service as long as the client does not qualify as “free” per TB program guidelines because the TB program does not have a required sliding fee scale.
c. If the only service that a client comes in for is a skin TST or IGRA due to employment, school, etc., it should go under the TB program type. However, if the client comes in for another service like MH, CH, or FP and it is determined as a part of the history that they are at high risk for TB and need a TST or IGRA, thenthat TST or IGRA should go under the program that the client is seen in. The basic rule is that the TST or IGRA was then related to the program that brought the client in and is determined by the purpose of the visit.
d. TB skin tests can be provided as a flat fee service as long as the client does not qualify as “free” per TB program guidelines because the TB program does not have a required sliding fee scale.
e. If the only service that a client comes in for is a skin test due to employment, school, etc., it should go under the TB program type. However, if the client comes in for another service like MH, CH, or FP and it is determined as a part of the history that they are at high risk for TB and need a skin test, then that TB skin test should go under the program that the client is seen in. The basic rule is that the TB skin test was then related to the program that brought the client in and is determined by the purpose of the visit.
1. EPI Program type is used for General Communicable Disease activities including Hepatitis A, Hepatitis B, food-borne outbreaks as well as other reportable disease investigations and follow-ups other than STD or TB. Clinical visits can be reported using the appropriate CPT Ccde, and there are LU codes that can be used to report activities that don’t fit into a CPT code.
2. EPI services cannot be charged to the client but if a clinical service is provided that is a billable service Medicaid may be charged. Other third party payers may be charged with permission from the client. For additional program guidance, please contact your Regional Communicable Disease Consultant or visit the program website at http://epi.publichealth.nc.gov/cd/lhds.html