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99211 for PPD Check

  1. #1
    Default 99211 for PPD Check
    Medical Coding Books
    I would like some feedback regarding billing a 99211 for a PPD check. If a patient comes in and have a 86580 with an evaluation and management services, we should then be able to bill a 99211 when the patient returns for a reading from the nurse 48 to 72 hours later.

    Please review the folowing supporting documentation.

    I think if the nurse does the PPD check and the doctor initials off on the results, then we should be okay to bill a 99211, if the doctor interprets the results, we would bill a regular office visit code instead of a minimal.

    The key will be to make sure that the nurse is performing the service with direct supervision of a physician under his written order, the results are documented and the doctor signs off.


    Has anyone billed this way and had any problems doing so?


    Bulletin Number: xxxxxx

    http://www.medscape.com/viewarticle/462014

    Tuberculosis Skin Tests

    Q. PPD (tuberculosis) intradermal skin tests involve injecting the PPD serum at one visit and examining the site two to three days later to see if any swelling has developed. Do I need to submit the CPT code for the intradermal skin test (86580) on the day the PPD is administered and then interpret the PPD for "free" on a subsequent day as a bundled service; or can I submit 99211 for the interpretation of the PPD by a nurse?

    A. You can submit 99211 if a patient requires subsequent evaluation of a test and no other service is performed. Medicare will also pay for this limited service. Note that if a nurse or other nonphysician provider who is unable to bill for this service under his or her own Medicare provider number performs this service under the physician's provider number, the "incident-to" requirements must be met. [For more information on Medicare's incident-to requirements, see "The Ins and Outs of 'Incident-To' Reimbursement," FPM, November/December 2001, page 23.]
    http://www.aafp.org/fpm/20080100/coding.html
    Diagnosis codes for PPD test
    Q What is the correct ICD-9 code for the purified protein derivative (PPD) skin test, CPT code 86580?
    A ICD-9 code V74.1 represents a special screening examination for pulmonary tuberculosis, including diagnostic skin testing for the disease. Often code V70.5, "Health examination of defined subpopulations," may be a secondary diagnosis to indicate the test is performed as part of a pre-employment or occupational health examination. Additional ICD-9 codes may be reported to indicate the patient's risk for tuberculosis. For example, report V01.1 for "Contact with or exposure to tuberculosis," 042 for HIV infection or 793.1 for "Nonspecific abnormal findings of radiological and other examination of the lung field."
    Remember that when a patient returns for the PPD reading, even when the reading is done by a nurse working incident to your services, you may report code 99211 for this evaluation and management (E/M) service.
    __________________________________________________ _______________
    Bulletin Number: xxxxxx

    CPT 2009 Manual, Professional Edition, Appendix C, page 497:

    Example of 99211:
    “Office visit for 42 year old, established patient, to read tuberculin test results”
    __________________________________________________ _________________
    http://coding.aap.org/content.aspx?aid=10858
    Which code is used to report the administration of the purified protein derivative (PPD)? When the patient is seen for the interpretation, can this be reported as a nurse visit and would the nurse be required to obtain vital signs?
    Code 86580 is used to report the administration of the intradermal (Mantoux) test for tuberculosis. It also includes the cost of the test itself. An E/M code may be reported when the test is interpreted. If the interpretation is performed and documented by a nurse or medical assistant (under the direct supervision of a physician), code 99211 (office or outpatient E/M service, minimal) would be reported. The nurse should document why the patient was seen, the date of the PPD administration, and results of the test. It is not a requirement that vital signs be taken because only medically necessary services need to be performed. The physician must cosign the documentation. If the physician interprets the test, the service is reported with the appropriate-level E/M code (99201–99215). Code V74.1 (special screening examination for pulmonary tuberculosis) is the appropriate diagnosis code to report when the test is administered and interpreted for screening purposes. If the test is administered to further evaluate an illness, use the diagnosis code for the illness or symptoms. If the test result is positive, report code 795.5 (nonspecific reaction to tuberculin skin test without active tuberculosis).
    __________________________________________________ ______________________________________


    The following is a MLN article that addresses “direct supervision” requirements
    http://www.cms.hhs.gov/mlnmattersart...ads/se0441.pdf

    “You do not have to be physically present in the patient's treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary.”
    Heather Winters, CPC, CFPC

  2. #2
    Default 99211 ppd
    I'm not entirely certain I would do this, I have read PPD's for years in the laboratory. It takes approximately 1 second to run your hand over an arm to feel if there is induration. It takes longer to document than it does to actually do the work and read it, which shouldn't take any time really. We always had the document ready to fill in the result, with the date delivered, the initials of the person planting and the location, already with the chart. Blanks are ready for date read, person reading and result.

    But, I can see charging a 99211 if there is a problem with it. I have seen some very extensive positive PPD's, in that case, I can definitely see the charge. The documentation is more extensive, and sometimes requires a second opinion, referrals, follow up appointments etc.

  3. #3
    Default PPD Check
    Thank you for the feedback. The guidance I have found so far do not limit the reporting to only positive findings. If we are going to bill for it, I'd like to do it the same across the board. See also page 34 of the following manual

    http://brightfutures.aap.org/pdfs/Pr...are%200908.pdf

    It states for administration code 86580 with V74.1, when they return for reading, code 99211 with V74.1 if it is negative, and 99211 with 795.5 if it is positive.
    Heather Winters, CPC, CFPC

  4. #4
    Default Ppd
    Your right, it does say that, so you would have some documentation to fight with if necessary. Your also right to do it consistently. It's too hard otherwise. My only issue is the documentation. All the documentation has to be there for a 99211 as it is an E/M code. How would you document anything other than the result? That's just not enough in my opinion to charge an E/M. If you can figure that out, I don't think it would be an issue.

  5. #5
    Default 99211 for PPD
    Documentation is tricky, 99211 is unique in that id does not have key component requirements like the other e/m codes.

    Our administration sheet is divided into three sections. The top has the patients name, dob, and social security number.

    The middle is the skin test administration area where time, date, location, dosage, manufacturer, lot number, expiration, and injection site is documented and then it is signed by the nurse.

    When the patient returns for the reading, the bottom half is completed with time, date, and the statement

    The above patients' TB test was read. The results were _________ millimeters of induration. The patient was referred for further medical evaluation ___ Yes ___ No. *if yes, the patient received "referral for medical evaluation" form.

    ______________ Patient's intiails
    _______________Reading Site

    _______________ Nurse Signature.
    Do you think that would be sufficient?
    Last edited by heatherwinters; 06-16-2009 at 12:59 PM.
    Heather Winters, CPC, CFPC

  6. #6
    Location
    Lauderdale Lakes, FL
    Posts
    19
    Default
    I do remember in older coding books seeing the "reading" of the PPD as an example for the 99211. Its not in the 2009 books, however.

  7. #7
    Location
    Jacksonville River City AAPC
    Posts
    240
    Default
    Heather,

    Something to add to the mix of your consideration is patient compliance with returning for the PPD check. This has less to do with 'can you bill for it' and more to do with 'do you really want to?'.

    If you start charging a 99211 for that visit, the patient will likely have an office visit co-pay that they will be responsible for. That means it can cost them up as much as $20 (or more depending on their carrier/contract) for that "one minute" visit - and they won't even see a doctor. You could end up with some un-intended consequences such as irate patients who may ulitmately leave the practice, increased patient A/R that might never be collected, and if word gets out, non-comliance with the patient returning for the check - an increased patient risk. In the long run, charging the 99211 for these types of 'visits' may cost the practice more than you want.
    Melissa Caperton, RHIA, CPC, CPMA, CPPM, CPC-I, CFPC
    Past Chair AAPC Chapter Association Board of Dirctors
    Past-President, River City AAPC
    Executive Co-Chair, Coding on the River

  8. #8
    Location
    Columbia, MO
    Posts
    12,531
    Default
    I agree with Melissa on this. Also many years ago a very wise person told me.. that the 8xxxx code for the administration of the PPD included the fact that test would be read and to charge again for that reading would be rude among other things. After I thought about that I decided he was correct, the PPD is nver given without the intention of returning the patient for a reading. If it is positive the nurse would need to get the physician involved anyway so it would become a physician encounter. Therefore I do not see any inconsistency with not charging for the reading if negative and having the physician evaluate if positive. Just a thought.

  9. #9
    Default PPD Check
    Thanks
    Heather Winters, CPC, CFPC

  10. Default HCPCS For PPD
    Is there a HCPCS code that is reported with the 86580?

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