TB chest xray & Z11.1

We are getting denials back from Humana Gold not covering diagnosis z11.1 for chest x-rays for nursing home placements. they are screening for TB. Does anybody have any documentation to get payment for these? (We bill Cahaba GBA as Medicare payer)

Thanks,
Dawn F
Radiology of Huntsville, PC

Comments

  • edited May 2017
    Hello,

    Humana is following CMS guidelines. CMS does not allow coverage for screening chest x-rays. It is not considered medically necessary and is not one of the preventive services they cover at this time.

    We used to have the issue with PPD screens all the times and I did this little write up below a while back that maybe can use to educate your ordering providers. It will need to have the ICD-9 converted to ICD-10 but otherwise the info is still accurate as far as I know.

    My other question is - why are they going straight to a chest x-ray and not do the TB skin test? That's odd. Maybe they did and it was abnormal? If that's the case, then yes you can get it paid with that diagnosis.

    :) Erica
    ------------------------

    Coding Fact Sheet — PPD Screening (86580)

    Medicare does not cover this test as a screening (dx V74.1).

    - Many patients who have Medicare AND MassHealth live in a facility. These facilities REQUIRE yearly PPD testing. This is fine — MassHealth pays without a problem after Medicare denies.

    - Other Medicare patients:

    Please consider the following before assigning code V74.1

    - Does patient have latent TB? If yes, assign code 795.51
    - Was pt exposed to TB? If yes, assign code V01.1
    - Does patient have signs and symptoms of TB (e.g. cough, hemoptysis, etc.)? If yes, assign the code for the symptom.
    - Did patient have an abnormal chest x-ray or CT Scan? If yes, assign code 793.19
    - Is patient on meds that put them at risk for PPD (Remicade, Orencia, prednisone)? If yes, assign the code for the condition being treated, e.g. RA.

    If none of the above applies and the test was truly a routine screening, this will not be covered by Medicare.
    The patient should be given an ABN so they have an opportunity to decide if they want the test and consent to be self-pay if/when claim denies.


  • I think if they have had a positive skin prick you need to use ICD10 dx..

    Karyn Cardenas-Foray, CPC, CPMA, CEMC, CIMC
    AHIMA Approved ICD10 Trainer
    Government Reimbursement Analyst
    Sharp HealthCare-PFS/CCD Spectrum
    (858)499-4382 ph.: (858) 499-4300 fax


  • Where I can find documentation on CMS that Medicare won't pay for a chest x-ray for TB screening or long term nursing care placement? I know they won't, but I don't know where to find it.

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