Home Forums Discussions General Discussion TB Tests and Coding

Folks,
As with so many things medical and billing this does not seem to be as straight up as it should be. How are all of you coding for TB skin tests? Nancy and I keep going around and around on this one. Now she wants to only give me the shot code for give the sub-q injection and nothing more. She claims that she read it somewhere like in Family Practice Managment or what have you, but that she can not produce the article now of discussion. Let's perform the mental exercise of breaking this all down. This is how I look at it.

1) Be it an injection or a puncture we are allowed to code and be paid for these and there is certainly a sub-q one of those here.

2) As long as we as using a consumable for an injection or sub-q type thing we are allowed to code and collect on those as well. In this case we are doing that as well. We certainly have to purchase and store on hand these various substances, and so we should certainly be entitled to be properly paid to do such.

3) At some point about 48 hours later a professional, you the doctor must examine this injection site and make a professional determination about this test, possible write a brief note to a school system or employer, and most importantly, document this for the record. So in a shot only situation shouldn't there be a related code and fee for this very real professional rendering and documentation, right???

Now let's say we have no real office visit associated with this test. It's just a TB test for whatever reason. Should't we have at least the three types of codes I just mentioned above. Shot admin fee, shot substance consumed, as well as some sort of professional office visit fee and code for the actual reading and documenting of this very important test? Makes sense to me.

Now let's say we did a 99391-99397 for some form of a well exam, I could see that possibly the reading and documenting of the test a day or two later might be considered as part of the original office visit, CPE thing. The same could be true if you were to code a more standard 99211-99215 for some sort of a tradidtional office visit surrounding some issue, including as just happened recently for a family of ours, possible exposure to a source of TB.

Dad and young son were both possibly exposed. Furthermore, because of this possible exposure we were back and forth with the Oswego county health Dept on these two patients. Now isn't there some sort of appropriate code for when a doctor has to interact with such agencies both for the individual's as well as the public's health? Nancy was on the phone, Shele and I were fielding calls and faxes and I'm sure Nancy had a good amount of charting to do for all of this mess. Some how, much like Bert's court apperances, aren't there proper codes and mechanisms for a doc to get paid for all this stuff?

If any of you know a good certified coder please run this by them for all of us. I curious about both the standard quiet TB test as well as the more intense possible exposure case. Dad and son were both SCHIP type patients and so here in NY the son's actual "vaccine" that was consumed probably came out of a pre-paid Vaccines for Kids lot, that we in general still submit for, but they then properly deny for that one part. I believe there is a special modifier we use to indicate it as such.

In closing as I always say to Nancy when she forgets to put in one or the other; when it comes to shots, these things always travel in pairs. Where there is a shot there is both the shot admin and the actual shot consumed itself. Shouldn't TB be at least the same, if not even something more for the reading and the charting of the test post the admin of the shot two days earlier???

Thanks very much,
Paul

You should not use the vaccination code (90471 or 90472) as you are not vaccinating. I do not use an injection code (90772) becuase it is NOT SUBCUTANEOUS NOR INTRAMUSCULAR. PPD is administered INTRADERMALLY. There is a article on PPD skin test in FPM. Essentially, I bill PPD intradermal as follows:
ICD-9 V74.1
CPT 86580
I charge for a 99211 or 99212 for interpretation 48 to 72 hours after the administration depending if a nurse reads this or I do.
I haven't found an intradermal administration code yet (but it may be the same code as "administration of lead projectile through the occiput for purposes of legal execution." I think this code pays better than what they pay pediatricians in Maine for "providing expert witness/deposition for DHHS with disruption to your clinical duties with upto a 12 hour waiting period."

Roy,
Nancy and I are just about rolling on the floor with your tongue in cheek humor. Thanks for belly laugh as well as the good advice. On the office visit thing I totally agree that it should be a medium size OV code. Otherwise, let's send the patients to the garage down the road to read, interprut and document their stupid tests. "Hey Carl can you take a look at this gals skin test for a moment???" I guess this means it's co-pay or what have you too, right?

Now let's say you had a CPE the day you admin'ed the test (shot them, lead projectiles?) or something, is it still another level 2 for the doc to read it two days later??? Or is it like removing suctures after sewing up a wound??? Those are just part of the previous procedure. Again I like the idea of the separate visit, as this make the most sense to me, but it's what those crazy CMS coding guys want that rules the day in our business, not what we actually know makes sense.

But we are free independent business people right? Even though the gov't and these large companies tell us how to bill and invoice our services... I guess I need some Nemenda, I forget so easily these days.... Thanks much.
Paul

Paul,

If a procedure does not require the "presence" of a physician, then it is a 99211. A 99212 needs a problem focused history and exam and straightforward decision making(2 out of 3). So unless the PPD comes out positive, there is really no NEED for a physician presence. I am sure some people will bill a 99212 but I am not sure it would hold up in an audit. We bill the 86580 when PPD placed and 99211 when they come back for the read. So far no positives!, but that would then become a doctor's visit and bill accordingly. I had my wife double check this and she does our billing and is never wrong (I am a good husband :-)

Some facilities are so small that there is no other person than the physician to read thePPD skin test. I only entrust myself to see the PPD skin test (as interpretation is not necessarily that easy). So many times I have had incorrect readings by stafftoo. 99212 is appropriate if the physician's time is used. Medicare does not require me to hire a nurse just to read the PPD skin test. Maybe Medicare should come up with a crazy requirement to mandate a nurse and a physician's assistant be on premesis so that there could be lower charges. Will help the unemployment rate too. Maybe I could chart "There was no nurse or physician's assistant present in the facility during the time this PPD skin test was read."

Boy you guys are giving me a lot of food for thought...Thanks, really. Yes we are one of those facilities that does not have a Nurse on staff to read these PPD's, Just wonderful Shele our Loyal Medical Assitant. If I'm not mistaken she can not read these for Nancy anyway. But both of you are onto something here, because althought we did have a negative result on those two family members that were exposed to the TB, there was an aweful lot of pre and post counceling along with it and interaction with Oswego county health dept too. I also agree that many of the things that assistants read and take should be "checked" by the doc...BP, Chem Strip Dips, PPD's. Can't tell you how many times I've seen these change when the doc does it too, just like Roy said. Again, thanks much for a great lively debate on all of this...Makes this board really worthwhile.
Have a great nite.
Paul

Coding question on AC board. Interesting
About PPD we bill 86580 for admisnitration and 99211 for the reading which most of the time is denied by commertial insurances, thus we bill the patient.
Now, some comments make me think. In our office we don't have RNs. Our experienced MA do the PPD reading.
To be able to bill for 99211 the service must be provided by a nurse? or a Medical Assistant MA can do it?

Regards,

Romel.

Romel,

You don't have to have an RN to be able to bill 99211 - an MA will do. Here is an article that explains when and how to use a 99211. http://www.aafp.org/fpm/20040600/32unde.html

Rainy:
Thank you for the link to the article.
It was informative.

I love this board!
OK, here's another coding question. When you perform a screening DRE as part of a complete exam and do a card hemoccult test, or you send cards home with the patient, what codes are you using?

Leslie

For females, I use:
CPT: Insertion of barrier protected blunt upper extremity phalanx for purposes of screening exam for malignancy with extraction of stool specimen, with or without local anesthesia, examination of prostate unspecified.

For males, I use:
CPT: Insertion of barrier protected blunt upper extremity phalanx for purposes of screening exam for malignancy with extraction of stool specimen with or without local anesthesia, with palpation of prostate.

CPT: Glove, non-sterile, disposable, latex, size not specified.


I couldn't resist. I'm just practicing writing new CPT codes. Perhaps, I could get a job with the AMA. Seriously, I believe we are only able to charge for the guaiac card testing. I use CPT(82270).

82270 or G0107 if Medicare.

It's my understanding that we should not be submitting that code until the cards are returned - and of course, we know how often that happens. I'd love to hear how others are doing it.

G0107 has been deleted earlier this year
Medicare doesn't pay for rectal exam/guaiac done in the office for preventive purposes anymore. They require 3 hemoccults cards be given to patient for home check to bill 82270
See the link http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5292.pdf

Apricot,
Nice to see you back on the board....

Apricot, thanks for the correction!

Are you billing the 82270 when you give them the cards or when they return them?

RE: TB tests

We charge $15 cash for them at time of injection. Then if they don't come back in time, it's on the pt to put up another $15. If they want their ins billed, they can try someplace else. We do contract out to some of the schools in town, but it's still the same price. Much less hassle and the pt is more likely to show up 48 hrs later when it's on their dime. It's way to time consuming for us to verify ins coverage for every little thing, or wait for ins to deny then bill pt. Nobody has ever complained so I guess this works.

Our GI doctors bill the 82270 when they give them cards, I do the same. Lately I have been sending patients for colonoscopy instead of giving them cards.