2025 ICD-10-CM code R76.11

Nonspecific reaction to a tuberculin skin test without active tuberculosis.

Follow current ICD-10-CM coding guidelines for reporting this code accurately.It is vital to code the appropriate encounter and any additional investigations. The clinical documentation must support the diagnosis.

Modifiers are not typically used with ICD-10 codes.

Medical necessity for a TST is determined by factors such as the patient's risk factors for TB, occupational exposure, or immigration history. The positive result, even in the absence of symptoms, necessitates additional testing and consideration for latent TB infection treatment.

The clinical responsibility involves interpreting the results of the tuberculin skin test, considering patient history, and determining the need for further evaluation or treatment. This may include chest x-rays, IGRAs, and/or treatment for latent tuberculosis infection.

IMPORTANT R76.12 (Nonspecific reaction to cell-mediated immunity measurement of gamma interferon antigen response without active tuberculosis) is used for IGRAs, such as QuantiFERON-TB Gold or T-SPOT.TB.Z11.1 (Encounter for screening for respiratory tuberculosis) may also be appropriate for the encounter where the test was performed. Z22.7 (Latent tuberculosis) is used to code a diagnosis of latent TB infection.

In simple words: This code means a skin test for tuberculosis (TB) showed a reaction, but you don't have active TB. The reaction shows you may have been exposed to TB bacteria in the past.More tests may be needed.

This code signifies a nonspecific reaction to a tuberculin skin test (TST), such as a Mantoux test, where the reaction is positive but there's no evidence of active tuberculosis.It indicates an immune response to the tuberculin antigen, suggesting prior exposure to Mycobacterium tuberculosis, but not necessarily an active infection.Further investigation may be needed to determine the clinical significance.

Example 1: A patient presents for a routine health screening, and a TST is administered. The test result is positive, but chest x-ray is negative, and the patient is asymptomatic. Code R76.11 is used to report the nonspecific reaction., A healthcare worker undergoes a TST as part of their occupational health evaluation. The result is positive, but further testing, including an IGRA, is negative. R76.11 is used., An immigrant patient undergoing a TB screening has a positive TST.Further workup is needed to confirm active infection or latent TB. The positive test reaction is coded R76.11 in conjunction with encounter codes as appropriate.

Detailed documentation should include the date of the TST, the method used (Mantoux), the reading of the induration, the date of the reading, the patient’s symptoms (if any), and any additional testing performed.

** This code should only be used when there is a nonspecific positive reaction to a tuberculin skin test without evidence of active TB.It is crucial to distinguish between a positive reaction to a test and an actual diagnosis of active or latent TB disease.

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