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.
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