ICD-10 Coding for Positive Tuberculosis Test(R76.11, Z11.1)
Complete ICD-10-CM coding and documentation guide for Positive Tuberculosis Test. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Positive Tuberculosis Test
R76.11Primary Range
Abnormal reaction to tuberculin skin test without active tuberculosis
Used for positive TB skin test results without evidence of active TB.
Encounter for screening for respiratory tuberculosis
Used for screening encounters where TB testing is performed.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R76.11 | Abnormal reaction to tuberculin skin test without active tuberculosis | Use when a tuberculin skin test is positive, but there is no evidence of active TB. |
|
| Z11.1 | Encounter for screening for respiratory tuberculosis | Use for preventive screening encounters. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for positive TB test
Essential facts and insights about Positive Tuberculosis Test
Primary ICD-10-CM Codes for positive tuberculosis test
Decision Criteria
clinical Criteria
- Induration of ≥5mm for high-risk groups, ≥10mm for others with risk factors, ≥15mm for low-risk individuals.
Applicable To
- Positive tuberculin skin test
Excludes
- Active tuberculosis (A15-A19)
Clinical Validation Requirements
- Induration measurement in mm
- Test type (e.g., TST or IGRA)
- Clinical context and risk factors
Code-Specific Risks
- Confusion with latent TB infection codes
Coding Notes
- Ensure documentation includes induration size and clinical context.
Z11.1 - Encounter for screening for respiratory tuberculosis
Use for preventive screening encounters.
Applicable To
- Screening for TB
Excludes
- Diagnostic testing for TB (R76.11)
Clinical Validation Requirements
- Screening encounter documentation
Coding Notes
Primary code for screening; sequence before R76.11.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for screening for respiratory tuberculosis
Z11.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Positive Tuberculosis Test to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R76.11.
Impact
Clinical: Inaccurate assessment of TB risk, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials
Mitigation Strategy
Ensure induration is measured and recorded, Use standardized templates
Impact
Reimbursement: Incorrect reimbursement rates, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate health data records
Mitigation Strategy
Use A15-A19 for confirmed active TB.
Impact
Inaccurate or incomplete documentation of TB test results.
Mitigation Strategy
Use standardized templates and ensure all required elements are documented.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Positive Tuberculosis Test, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Positive Tuberculosis Test
Use these documentation templates to ensure complete and accurate documentation for Positive Tuberculosis Test. These templates include all required elements for proper coding and billing.
Occupational Health TB Screening
Specialty: Occupational MedicineRequired Elements
- Patient name
- Date of test
- Induration size
- Reader's name
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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