Find information on Tuberculosis screening, including clinical documentation requirements, medical coding (ICD-10 codes A15-A19, Z11.1), and healthcare guidelines. Learn about TB test interpretation, latent TB infection (LTBI) diagnosis, and active TB disease management. Resources for physicians, nurses, and other healthcare professionals involved in TB control and prevention.
Also known as
Encounter for screening for TB
Encounters for tuberculosis screening tests.
Respiratory tuberculosis
Includes codes for active and latent TB.
Abnormal immunological TB test
Abnormal results from tuberculosis immunological tests.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the screening for latent TB infection?
Yes
Is the test positive?
No
Is the screening for active TB disease?
When to use each related code
| Description |
|---|
| Tuberculosis screening |
| Latent tuberculosis infection |
| Active pulmonary tuberculosis |
Coding Z11.1 without documenting the specific type of screening (TST, IGRA, etc.) leads to undercoding and lost revenue. CDI can query for clarification.
Incorrectly coding active tuberculosis (A15-A19) as screening (Z11.1) impacts quality reporting and reimbursement. CDI and audit reviews are crucial.
Failing to code history of TB (Z86.11) when documented, along with screening, impacts risk adjustment and care planning. CDI can identify this gap.
Tuberculosis screening conducted on [Date] for patient [Patient Name], [Medical Record Number]. Patient presents with [Risk factors for TB exposure; e.g., recent travel to endemic area, close contact with known TB case, history of incarceration, healthcare worker, immunocompromised state]. Reason for encounter documented as [e.g., latent tuberculosis infection screening, active tuberculosis disease investigation, contact tracing, pre-employment screening]. Assessment includes review of symptoms, past medical history, social history, and occupational exposures. Patient reports [Symptoms; e.g., cough, fever, night sweats, weight loss, fatigue, hemoptysis; or denies symptoms if asymptomatic]. Physical examination reveals [Findings; e.g., clear lung sounds, normal respiratory rate, no lymphadenopathy; or document any relevant positive findings]. Tuberculin skin test (TST) administered with [PPD strength] resulting in induration of [Measurement in millimeters] after [Time elapsed] hours, interpreted as [Interpretation; e.g., positive, negative, borderline]. If TST positive or indeterminate, interferon-gamma release assay (IGRA; e.g., QuantiFERON-TB Gold, T-SPOT.TB) ordered. IGRA result [Result; e.g., positive, negative, indeterminate]. Chest X-ray [Ordered, performed, findings; e.g., PA and lateral chest X-ray ordered, findings unremarkable]. Differential diagnoses include [Other potential causes; e.g., pneumonia, bronchitis, lung cancer]. Plan: [Next steps; e.g., referral to infectious disease specialist, initiate latent TB treatment with isoniazid, further investigation with sputum culture and acid-fast bacilli smear if active TB suspected, patient education regarding TB transmission and prevention]. ICD-10 code: [Appropriate ICD-10 code, e.g., Z11.1 for encounter for screening for tuberculosis, A15.0 for respiratory tuberculosis, R76.1 for abnormal tuberculin skin test without documented diagnosis]. CPT code: [Appropriate CPT code, e.g., 86580 for TST, 86481 for IGRA]. Patient advised to follow up [Follow-up instructions].