Coverage Policy Manual
Policy #: 2012039
Category: PPACA Preventive
Initiated: August 2012
Last Review: November 2023
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: TUBERCULOSIS SCREENING
Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  Additionally, the law requires coverage of Bright Futures recommendations for children from the American Academy of Pediatrics, preventive services for women outlined by the Health Resources and Services Administration’s (HRSA’s) Women’s Preventive Services: Required Health Plan Coverage Guidelines and all vaccinations recommended by the Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention.
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Bright Futures was established by the Health and Human Services (HHS) Health Resources and Services Administration’s Maternal and Child Health Bureau with the mission to “promote and improve the health, education, and wellbeing of infants, children, adolescents, families and communities” (AAP, 2008).
 
Bright Futures describes its guidelines as “evidence informed rather than fully evidence driven” (AAP, 2008). Unlike the USPSTF, Bright Futures does not assign grades to recommendations that do not definitively recommend for or against a particular preventive service. Rather than leave gaps in the recommendations, Bright Futures supplements evidence with experience and expert opinion to ensure that definitive guidance is given (IOM, 2011).
 
The following policy is based on the U.S. Preventive Services Task Force and Bright Futures recommendation for this preventive service.
 
Policy/
Coverage:
Effective January 2018
 
Tuberculosis screening is covered for members of all ages who are assessed to be at an increased risk for tuberculosis.
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z11.1, Z11.7 and Z20.1.
 
Codes that may be used to report this service include CPT 86580 and 86480.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
Effective Prior To January 2018
 
Tuberculosis screening is covered for infant, child and adolescent members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay). Selective screening should begin with the tuberculin skin test for infants, children and adolescents who are at increased risk based on risk screening questions, at the first month well-child visit and continue through adolescence.
 
The appropriate ICD-9 codes to report these services are V70.0, V74.1 or V01.1.
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z11.1 and Z20.1.
 
Codes that may be used to report this service include CPT 86580.  
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
 
 
Rationale:
The Third Edition of Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents recommends selective screening for tuberculosis using risk assessment screening questions at the 1 month, 6 month, 12 month 18 month 24 month, 4 year, 6 year, 8 year, and 10 year well-child visit and  annually following that until 18 years of age (Hagan, 2008).   It is recommended that screening be done once between the ages of 18-21 (Hagan, 2008).  Tuberculin skin testing per recommendations of the Committee on Infectious Diseases, published in the current edition of Red Book Report of the Committee on Infectious Disease (AAP, 2012). Testing should be done on recognition of high-risk factors.
 
Risk assessment questions may include the following:
 
  • Was your child born in a country at high risk for tuberculosis (countries other than  the United States, Canada, Australia, New Zealand, or Western Europe)?
  • Has your child traveled (had contact with resident populations) for longer than 1
 week to a country at high risk for tuberculosis?
  • Has a family member or contact had tuberculosis or a positive tuberculin skin test?
  • Is your child infected with HIV?
 
 2017 Update
The USPSTF issued a recommendation for tuberculosis screening September 2016. The recommendation includes screening for latent tuberculosis infection in populations at increased risk. The recommendation applies to asymptomatic adults 18 years of age and older.
 
The USPSTF recommendations include the following information (USPSTF, 2016):
    • Populations at increased risk for LTBI based on increased prevalence of active disease and increased risk of exposure include persons who were born in, or are former residents of, countries with increased tuberculosis prevalence and persons who live in, or have lived in, high-risk congregate settings (eg, homeless shelters and correctional facilities). Clinicians can consult their local or state health departments for more information about populations at risk in their community, because local demographic patterns may vary across the United States.
    • In 2015, among persons of known national origin, 66.2% of all active tuberculosis cases in the United States were among foreign-born persons, and the case rate of active tuberculosis among foreign-born persons was approximately 13 times higher than among US-born persons (15.1 vs 1.2 cases per 100,000 persons). More than half of all foreign-born persons in the United States with active tuberculosis were from 5 countries: Mexico, the Philippines, Vietnam, India, and China.7 In addition, the CDC has identified foreign-born persons from Haiti and Guatemala as important contributors to active tuberculosis cases in the United States. The World Health Organization (WHO) recently updated its list of countries with a high burden of tuberculosis to include the top 20 countries with the highest absolute numbers of cases and an additional 10 countries with the most severe burden in terms of case rate per capita.
    • Persons who live in, or have lived in, high-risk congregate settings also have a higher prevalence rate of active tuberculosis and increased risk for exposure. Among persons 15 years and older with active tuberculosis, 5.6% were homeless within the past year, 2.2% were residents of a long-term care facility, and 4.2% were in a correctional facility at the time of diagnosis. Published prevalence rates of LTBI in these settings vary widely, depending on the type of screening test used, the TST threshold used to define the presence of LTBI, and the population studied. Estimates of LTBI prevalence range from 23.1% to 87.6% among prisoners and from 18.6% to 79.8% among persons who are homeless.
    • Other populations at increased risk for LTBI or progression to active disease include persons who are immunosuppressed (eg, persons living with human immunodeficiency virus [HIV], patients receiving immunosuppressive medications such as chemotherapy or tumor necrosis factor-alpha inhibitors, and patients who have received an organ transplant) and patients with silicosis (a lung disease). However, given that screening in these populations may be considered standard care as part of disease management or indicated prior to the use of certain medications, the USPSTF did not review evidence on screening in these populations. Some evidence from observational studies has explored the association between poorly controlled diabetes and progression of LTBI to active disease. However, there is insufficient evidence on screening for and treatment of LTBI in persons with diabetes for the USPSTF to make a separate recommendation for this important subgroup.
    • Persons who are contacts of individuals with active tuberculosis, health care workers, and workers in high-risk congregate settings may also be at increased risk of exposure. Since screening in these populations is conducted as part of public health or employee health surveillance, the USPSTF did not review the evidence in these populations. Clinicians seeking further information about testing for tuberculosis in these populations can refer to the “Useful Resources” and “Recommendations of Others” sections.
 
Screening Tests
    • Two types of screening tests for LTBI are currently available in the United States: the TST and IGRA. The TST requires intradermal placement of purified protein derivative and interpretation of response 48 to 72 hours later. The skin test reaction is measured in millimeters of the induration (a palpable, raised, hardened area or swelling). Interferon-gamma release assays require a single venous blood sample and laboratory processing within 8 to 30 hours after collection. Two types of IGRAs are currently approved by the US Food and Drug Administration: T-SPOT.TB (Oxford Immunotec Global) and QuantiFERON-TB Gold In-Tube (Qiagen).
    • Numerous patient and systems factors may influence the selection of a screening test. Generally, the CDC recommends screening with either the TST or IGRA but not both. Testing with IGRAs may be preferable for persons who have received a bacille Calmette–Guérin vaccination or persons who may be unlikely to return for TST interpretation. Additional information on the use and interpretation of the TST and IGRA is available from the CDC.
 
Screening Intervals
    • The USPSTF found no evidence on the optimal frequency of screening for LTBI. Depending on specific risk factors, screening frequency could range from 1-time only screening among persons who are at low risk for future tuberculosis exposure to annual screening among those who are at continued risk of exposure. 
CPT/HCPCS:
86480Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon
86580Skin test; tuberculosis, intradermal
References: AAP Committee on Infectious Disease: Pickering L., Baker C.J., Kimberlin D.W., Long S.S. (Eds.) .(2012) Red Book®: 2012 Report of the Committee on Infectious Diseases. American Academy of Pediatrics.

Hagan JF, Shwa JS, Duncan PM, eds.(2008) Bright Futures: Guidelines for health supervision of infants, children and adolescents, 3rd ed. (J. F. Hagan, J. S. Shaw, and P. M. Duncan, eds.). Elk Grove Village, IL: American Academy of Pediatrics.

IOM (Institute of Medicine).(2011) Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Acadamies Press.

U.S. Preventive Services Task Force (USPSTF).(2016) Final Recommendation Statement. Latent Tuberculosis Infection: Screening. September 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/latent-tuberculosis-infection-screening. Last accessed November 11, 2017.
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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