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TB Notes Newsletter

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No. 3, 2012

CDC Reports from the National TB Workshop

TB Programs and Billing in the Age of the Affordable Care Act

The Patient Protection and Affordable Care Act (ACA) includes provisions that can change the way TB prevention and control services are delivered. With larger numbers of persons having health insurance beginning in 2014, TB and other public health programs will serve more people who are covered under some type of plan. For the first time, TB programs may find that it makes sense to set up systems to bill Medicare, Medicaid, or private health insurance companies (known as “third parties”) for TB services.

To explore this opportunity, DTBE hosted a roundtable discussion titled “The Impossible Dream? Billing for Services in the Era of Budget Cuts” at the 2012 National TB Workshop. Approximately 75 participants attended. The roundtable allowed personnel from TB programs that have begun billing to share information about their procedures, as well as information that could be used in determining whether to set up systems for billing. Speakers included Victor Balaban, PhD, and Christine Ho, MD, from DTBE/NCHHSTP, and Duane Kilgus, MPH, and Toscha Stanley, MHSA, from the National Center for Immunization and Respiratory Diseases (NCIRD).

Victor Balaban started off the session by providing an overview of ACA as it relates to TB prevention and control. Some of the main points included describing the potential impact for TB prevention and control programs of shifts in funding away from the health department (HD) setting as newly insured patients are treated in Federally Qualified Community Healthcare Centers (FQCHCs). TB differs from many other communicable diseases in that there are essential TB control activities (e.g., case reporting, contact tracing, legal orders) that cannot be done by private providers. Since many HDs are facing budget cuts in the immediate future, it may now make sense for at least some TB programs to develop billing procedures as a way to replace a portion of the lost resources. Dr. Balaban emphasized that DTBE is not currently recommending implementation of third-party billing, but is providing information to help programs make their own decisions. Resources include other relevant programs within CDC such as the NCIRD Billables Project, other TB programs with billing experience, and relevant professional organizations, e.g., the American Thoracic Society Coding & Billing Quarterly, the Medical Association of Billers, and the American Academy of Professional Coders.

Christine Ho provided a handout that outlined the basic components of the ICD-9 billing codes and described codes that are currently being used by some TB programs to bill for TB services. For example, ICD-9 codes exist for TB screening with TB skin test or blood-based interferon gamma release assay (IGRA), diagnostic evaluation for contacts and TB suspects, and treatment of active cases. The extent to which programs bill varied greatly, from some billing for only a few select services (such as IGRA testing) to others billing comprehensively for all patient care including directly observed therapy. The impact of compensation for TB services on program budgets and service delivery also varied widely, from one small health department bringing in less than $5,000 yearly to another urban program bringing in more than $600,000 yearly. Patient volume, insurance status, and whether medical doctors provide services on site are also factors in how much money can be recouped for a program. Lastly, most programs that billed either partnered with a hospital or other facility that was already billing, or hired a contractor to handle the intricacies of billing.

Duane Kilgus and Toscha Stanley presented an overview of the NCIRD Billables Project, which funded 14 state grantees to develop and 14 more to implement billing plans for immunizations. Mr. Kilgus noted that billing rules and requirements vary between states; he stressed the importance of programs conducting self-evaluations of their current needs, as well as the resources they have that may support a billing program. State-specific billing toolkits were developed by many of these sites. He described some of these resources available through the NCIRD Billable Project website, such as the Public Health Billing Resource Manual developed by the state of Georgia and the Local Health Jurisdiction Immunization Billing Resource Guide developed by the State of Washington. Ms. Stanley reviewed success stories, as well as barriers, that had been encountered by programs in implementing billing programs. She concluded that not all programs can or should bill for services, but all programs should evaluate whether it makes sense for them to bill.

After the presentations, Dr. Ho led a question-and-answer session during which TB program representatives from programs that are billing shared their experiences. Some programs described their success in billing, while others questioned the overall net benefit after accounting for the extra personnel required to bill. Some programs have not established billing procedures for various reasons, such as concern that compensation received would go into a general fund that would not benefit the TB program. Another TB program tracked the monies contributed into the general fund to leverage for funding TB services.

Overall, the roundtable was a great success. We look forward to sharing additional information as TB programs adapt to changes in health care delivery under ACA. Please feel free to contact Victor Balaban,, Christine Ho,, or Duane Kilgus for further questions or information.

—Reported by Victor Balaban, PhD, Christine Ho, MD, and Ann Cronin
Div of TB Elimination
and Duane Kilgus, MPH, RS

2010 Tuberculosis Follow-Up Examination for Immigrants and Refugees Who Relocated to the United States with TB Conditions

Background: Approximately 400,000 immigrants and refugees legally immigrate to the United States each year; on average, 23,000 arrive with tuberculosis (TB) conditions. The Electronic Disease Notification system (EDN) notifies state and local public health officials of immigrants and refugees identified with suspected TB during their overseas medical examination. Arrivals with suspected TB are strongly recommended to undergo a post-U.S. arrival TB follow-up examination to help lower the risk of spreading TB to the U.S. population. Domestic TB programs conduct follow-up examinations of these immigrants and refugees and report results to CDC through EDN. Health departments can electronically submit the domestic TB follow-up examination results by using the TB Follow-up Worksheet in EDN (Figure A).

Figure A. US TB follow-up worksheet
US TB follow-up worksheet US TB  follow-up worksheet

U.S. national TB surveillance reports have shown that the U.S. foreign-born population is at a higher risk for developing TB disease than the U.S.-born population.(1) Epidemiologic studies have shown that among foreign-born persons, most TB cases occurred during the first few years after arrival in the United States.(2) Domestic examination results for newly arrived immigrants and refugees as reported to EDN were evaluated to determine the domestic TB follow-up rate and final TB diagnosis. We analyzed examination outcomes to help gauge U.S. TB prevention efforts for recent Class B arrivals.

Methods: Immigrants and refugees must complete a comprehensive physical and mental examination as part of the U.S. visa application process. To reduce the risk of spreading TB in the U.S., immigrants and refugees are evaluated for TB using the TB Technical Instructions (TI) overseas by panel physicians and domestically by civil surgeons. We analyzed domestic follow-up examination results for persons with an overseas diagnosis of Class B TB who arrived in the United States during 2010. Class B TB is defined as the following: having a chest radiograph consistent with TB but with negative sputum smears (1991 TB TI) or negative sputum smears and sputum cultures (2007 TB TI); or children 2–14 years of age with latent TB infection (LTBI) (2007 TB TI); or being a contact of a TB case (2007 TB TI).

Figure B.  Class B arrivals, by country of origin (N=24,728), 2010
Class B arrivals, by country of origin (N=24, 728), 2010
Results: In 2010, EDN notified U.S. health departments of 24,728 arrivals with Class B TB. Of these, 17.3% were refugees, 81.6% were immigrants, and 1.1% held other U.S. visas. The Philippines was the country of origin for a majority of these arrivals (38.4%), followed by Vietnam (11.7%) and Mexico (10.3%) (Figure B). The overseas examinations were performed according to the 2007 TB TI for the majority (91.1%) of these arrivals. Domestic follow-up examination results were reported for 80.4% of the Class B arrivals. Of those with reported outcomes, 80.9% had completed examinations, 5.5% examinations were initiated but not completed, and 13.6% did not have an examination started. Among those with a completed examination, 1.3% (223) were diagnosed with active TB and 42.3% were diagnosed with LTBI (Figure C).

Figure C. Post-US arrival TB diagnoses as reported by US health departments, 2010
Post-US arrival TB diagnoses as reported by US health departments, 2010

Conclusion:  TB follow-up examination results are reported to EDN on a continuous basis. The high percentage of TB and LTBI diagnosed in the Class B cohort highlights the importance of timely and thorough follow-up examinations for TB. U.S. examination outcomes for 19.6% of Class B arrivals have not yet been reported to CDC through EDN. To increase the number of TB and LTBI cases identified and treated, efforts should be increased to address any challenges or barriers to TB follow-up examination and reporting.

—Reported by Kendra Cuffe, MPH, Nekeia Gray, Meghan Weems, MPH,
John Painter, DVM, MS, and Rossanne Philen, MD, MS
Div of Global Migration and Quarantine


  1. CDC. Trends in tuberculosis – United States, 2011. MMWR 2012; 61:181-185.
  2. Cain KP, Benoit SR, Winston CA, et al. Tuberculosis among foreign-born persons in the United States. JAMA 2008; 300 (4): 405-412.

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