Pediatric Coding Alert

Can you correctly code this common pediatric encounter?

It’s a familiar coding situation for most pediatric coders. A 6-year-old reports to your office for a tuberculosis skin test.

But do you know what codes you can, and cannot, use to report the encounter? And what are the coding options if the test comes back negative or positive?

Read on, and pit your coding expertise against our experts’.

Which Code do You Use for the Initial Encounter?

The correct code for billing a skin test, delayed hypersensitivity test (DHT or DHR), Mantoux test, tuberculin skin test, or purified protein derivative test (PPD) to screen for tuberculosis is 86580 (Skin test; tuberculosis, intradermal). As this is a screening test, you’ll add Z11.1 (Encounter for screening for respiratory tuberculosis) to 86580.

“There are two additional tests that can be performed to detect tuberculosis,” Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico, reminds coders. However, 86480 (Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon) and 86481 (Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension) “are normally only for testing immunosuppressed patients, because the skin test is not as sensitive for this type of patient,” Witt explains.  

“In other words, they would not usually be performed on an otherwise normal pediatric patient,” Witt adds.

Coding alert: As the skin test involves injecting a sterile extract of tuberculin, it is possible to confuse the testing code for vaccine administration. However, under no circumstances should you code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) or 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) for the test, as both are for immunization, which is not the purpose of the testing service.

Can You Bill for an Administration/Injection Fee or an E/M in Addition?

“Coders often question whether a clinic can bill for injecting the antigen for this skin test,” says JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis, Minnesota. “The answer is that the injection is also included in 86580, so it would not be appropriate to report 96372 [Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular] with 86580 unless the patient was a receiving a distinct and separate therapeutic injection at the same visit as the PPD test,” Wolf goes on.  

“Some coders get confused because National Correct Coding Institute [NCCI] edits indicate that the 86580 and 96372 may be reported together with a modifier, but billing 96372 for simply injecting the antigen would not be considered distinct or separate,” Wolf explains. “Besides, 96372 would not be appropriate for a subdermal injection, which is what the nurse is doing when testing for TB,” Wolf adds.

As for billing for an evaluation and management (E/M) service in addition to 86580, “if the pediatric patient also requires vaccination on the date of service, or the pediatrician documents a separate significant E/M service as well, these services can also be billed,” Witt says. Just remember to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the appropriate E/M.

Can You Bill for the Reading?

“According to the American Academy of Pediatrics [AAP], 86580 does not include reading the test,” says Witt. Consequently, as the interpretation involves a nurse reviewing the patient’s history and medical chart and examining the patient’s skin, “you can bill 99211 [Office or other outpatient visit for the evaluation and management of an established patient …] if this is the only reason the patient is presenting to the office,” Witt argues.

Typically, if the test turns out positive, the patient will need to have a face-to-face discussion with your pediatrician regarding the diagnosis, further evaluation, and possible treatment. Under these circumstances, “a higher level of E/M may be appropriate if the clinician then has to see the patient,” Witt adds.

Final Words of Advice

“According to the AAP, TB skin testing is not indicated for low-risk patients,” according to Witt. Instead, the test “should be reserved for high-risk pediatric patients,” Witt cautions coders.

In addition, you should also pay attention to the patient’s age in this scenario, as “blood tests for TB such as 86480 and 86481 are not recommended for children under the age of 5,” Witt concludes.