Tuberculosis skin test (TST) performed on DATE.  Patient presented for tuberculosis screening due to REASON FOR TEST (e.g., occupational exposure, contact investigation, immigration requirement, pre-employment screening, routine medical examination).  Medical history pertinent to tuberculosis risk factors reviewed, including history of prior positive TST, BCG vaccination status, country of origin, HIV status, immunosuppression, and close contact with individuals with active tuberculosis.  Patient denies symptoms suggestive of active tuberculosis, including cough, fever, night sweats, weight loss, and hemoptysis.  Mantoux method utilized with 0.1 mL of purified protein derivative (PPD) tuberculin injected intradermally into the volar surface of the left forearm.  Induration measured at 48-72 hours post-injection and recorded as MEASUREMENT mm.  Result interpretation based on current CDC guidelines considering patient risk factors.  Differential diagnoses considered include latent tuberculosis infection (LTBI), active tuberculosis disease, false-positive reaction due to prior BCG vaccination or nontuberculous mycobacterial infection, and false-negative reaction due to anergy or recent infection.  Treatment plan discussed with patient based on TST result and individual risk assessment.  Patient education provided regarding tuberculosis transmission, signs and symptoms of active disease, and importance of adherence to recommended treatment if indicated.  Referral to infectious disease specialist may be considered for further evaluation and management if appropriate.  ICD-10 code Z11.1 (Encounter for screening for tuberculosis) or R76.11 (Abnormal reaction to tuberculin skin test, unspecified) may be applicable depending on the result.  CPT code 86580 (Skin test; tuberculosis, by Heaf or Mantoux technique) used for billing.