Tuberculin Testing

Skin Testing

Skin testing is covered once per benefit year (January – December) for adults and as needed for children. Tuberculin (TB) Risk Questionnaire is covered according to regular plan benefits. If an adult patient fails to return for the reading and needs to retake the test, the patient is responsible for the cost of the second test. This must be explained to the patient and the patient must sign a financial responsibility statement before the second test is done. An exception is made if the initial test results are positive or inconclusive. This information must be noted on the claim for the second testing to help ensure processing of the claim.

Claims Filing Information

Use the appropriate CPT-4 code describing the service provided. The fee paid for the testing includes the reading of the test results. A separate visit to read the results is not payable.

There is no corresponding procedure code for the TB Risk Questionnaire. Claim should include any service(s) actually rendered (e.g., if the primary reason the patient saw the provider was to get a TB clearance, claim would be billed for a low-level evaluation and management visit such as 99211, etc.), and regular plan benefits would apply. Note: Plans must have screening benefits when billed for screening purposes.

When testing children as part of an EPSDT screening exam, the testing is included as part of the global fee reimbursement for EPSDT and should not be billed separately.

If this is a second test for an adult because the initial test was positive or inconclusive, include a notation in field #19 to explain the reason for the test.

I. CPT code 86580

1. Criteria/Guidelines
   1. CPT code 86580 is used to describe all intradermal TB tests, including TB skin tests, TB delayed hypersensitivity tests (DHT or DHR), Mantoux and/or tine tests and the purified protein derivative test (PPD).
   2. HMSA payment for CPT code 86580 includes payment for the material used, the administration of the test and the reading of the test. HMSA does not provide separate reimbursement for the administration or reading of the TB test.
2. Benefits
   1. TB testing is covered under Well-Baby Care.
   2. TB testing is also covered in older children and adults.
   3. Payment for TB skin testing is based on plan benefits for diagnostic testing.

II. CPT code 86480

1. Criteria/Guidelines
   1. CPT code 86480 is defined by CPT as "Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response." The test is a blood test, not a skin test.
   2. The test is more specific (producing fewer false positives) than the current skin test and, unlike the skin test, does not require a return visit by the patient to the practitioner's office for interpretation.
   3. The Centers for Disease Control and Prevention (CDC) has recommended that the test should not be used on patients who are:
      1. Immunocompromised
      2. Under age 17
      3. Pregnant
      4. Suspected with active tuberculosis or contacts of persons with infectious tuberculosis
2. Benefits
   1. HMSA provides coverage for this test for members age 18 and older.
   2. HMSA plan benefits for laboratory services will be applied.

III. References

For complete information about CDC recommendations see Guidelines for Using the QuantiFERON - TB Test for Diagnosing Latent Mycobacterium tuberculosis Infection.

Revision History