This policy replaces all previous statements from the Division of Tuberculosis Control (DTC) relating to the use of chest radiography in the evaluation of patients with TB infection, confirmed or suspected TB disease, including Policy TB 99-002 issued in January of 1999.
Background and Rationale | Policy Implementation | Scope and Coverage | Chest radiographic services not covered under this policy | Rates of reimbursement | Treatment recommendations and medical consultations
I. Background and Rationale
For many years, DTC maintained a chest radiography program that enabled districts with low or intermediate prevalence of TB to provide these services at no charge to their clients with TB disease or infection. Areas with higher prevalence of TB assumed responsibility for this service long ago. Changes in national guidelines prompted reexamination of this policy with an aim toward intensifying the DTC focus on activities of higher priority in TB control. In January 2001, DTC implemented a revised chest radiography program that operates under the guidelines detailed below. These changes maintain DTC's strong commitment to eliminating barriers to the care of all patients with TB disease and selected groups of persons with TB infection. It is hoped that these changes will ensure that DTC can continue to provide radiographic services at no charge to these groups of patients for some time to come.
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A) This program is open to all health districts in Virginia that participated in the previous chest radiograph program, ended by this policy. By participating in this program, the Health District agrees that no processing fees or other types of co-payment will be billed to or collected from clients in return for arranging for a radiograph obtained under this program.
DTC will continue to provide financial support for chest radiographs obtained for selected tuberculosis-related indications. This support will be provided under a system of reimbursement whereby districts will received a fixed amount (see Section VI below) for each film that meets at least one of the following eligibility criteria:
1. All patients with symptoms suggestive of TB disease, regardless of the tuberculin reaction. These symptoms include, but are not limited to: cough of duration greater than 3 weeks, fever, night sweats, unexplained weight loss, and/or hemoptysis
2. All contacts of persons with active TB disease who meet one or more of the following criteria:
a) a new, significant reaction (>5mm induration) in the tuberculin skin test.
b) symptomatic for tuberculosis
c) immunosuppressed, regardless of symptoms or tuberculin reaction
d) children 4 years of age and under, regardless of symptoms or tuberculin reaction
3. Patients with confirmed or suspected pulmonary tuberculosis, currently undergoing evaluation or treatment and requiring films to assess the clinical course of disease. In general, persons with disease due to drug sensitive organisms, who are responding clinically and bacteriologically to standard chemotherapy, do not require chest radiographs during therapy. However, a film obtained shortly after completion of therapy is recommended to document the extent of residual abnormalities. Therefore, reimbursement under this indication will be limited to two films per patient. Additional studies will be approved after consultation with either the physician or nurse consultant from DTC.
4. Patients who have completed a course of treatment for confirmed or suspected tuberculosis and in whom a final film is required to establish a new baseline (see above)
5. Patients with a history of old TB infection or treated and cured tuberculosis disease who have current symptoms suggestive of TB disease
6. Patients with a history of MDR-TB that has been treated and cured, but who require ongoing follow-up to document the lack of recurrence.
7. Newly arrived immigrants and refugees, belonging to TB Class A, B1, or B2, in whom a radiograph is indicated to confirm status.
8. Patients with confirmed or suspected (based on documented risk factors) HIV infection who are found to be recently co-infected with M. tuberculosis
9. Patients in other categories, only after prior consultation with one of the following individuals in this office: Margaret (Peg) Tipple, MD (Director), Jane L. Moore (Nurse Consultant). In the absence of medical personnel, please consult with Wendy Heirendt (Public Health Advisor). DTC staff can be reached at 804-864-7906 during business hours (M-F, 8:30am-4:30pm).
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III. Chest Radiographic Services Not Covered Under This Policy
A) Each health district may decide, at its discretion, to offer films for additional indications and at whatever cost to the client as established by VDH policy. Reimbursement from DTC will be made only for those films meeting the criteria outlined above.
B) The following are examples of chest radiographs, though medically-indicated, that will not be eligible for reimbursement from DTC:
1. Asymptomatic patients with newly identified latent tuberculosis infection found as part of a health-department sponsored screening effort. It is recommended that all health-department sanctioned screening programs center on members of standard risk groups for tuberculosis disease and include provisions for interpretation of chest radiographs obtained, prescription of treatment, appropriate clinical and/or laboratory follow-up to assure completion of therapy.
2. Asymptomatic persons referred by private providers for tuberculin testing and/or chest radiograph
3. Asymptomatic members of high-risk groups (excluding those with HIV infection) who present to the health department for tuberculin skin testing and chest radiography as indicated
4. Asymptomatic persons who present to local health departments for employer-required tuberculosis screening. Examples include school employees, health care workers, and day care employees.
5. Asymptomatic prison employees and inmates referred to the health department for screening.
6. Asymptomatic women who are referred for prenatal tuberculosis screening
7. The Refugee Health Program has facilitated reimbursement from the Division of Social Services for the Health Assessment services provided to refugees. The evaluation for tuberculosis is a part of this assessment and the level of reimbursement is sufficient to cover the costs of chest radiography and interpretation when indicated. Except for those individuals that enter the United States with current or prior tuberculosis disease (Class A, B1, and B2), radiographs on refugees will not be eligible for additional reimbursement from the DTC.
C) Listed below are examples where chest radiography is not usually medically indicated. It is suggested that local health departments maintain DTC’s long-standing policy of not providing chest radiography for these indications.
1. Follow-up CXR obtained on asymptomatic individuals at the completion of preventive therapy
2. Routine follow-up films on asymptomatic patients who have been previously treated and cured of confirmed tuberculosis (excluding MDR-TB)
3. Asymptomatic, tuberculin-negative contacts of patients with active tuberculosis disease (excluding the immunosuppressed and children 4 years of age and under)
4. Annual employment “screening” films on asymptomatic patients with a history of tuberculous infection or treated and cured tuberculosis disease
5. Routine films on asymptomatic, refugees, immigrants, migrant/seasonal workers, other foreign-born groups, or homeless persons unless they meet the criteria outlined in Section IIB or Section IIIB.
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IV. Treatment Recommendations and Medical Consultations
A) Responsibility for making treatment recommendations based on a clinical evaluation of the patient and chest radiograph will ultimately rest with a locally based physician. Until local physician services have been arranged, DTC will continue to provide treatment recommendations for patients fulfilling at least one of the criteria listed above in Section IIB. All cases submitted for evaluation must include the current film, any old films that are available, the TB512 and any other supporting information necessary for a clinical decision to be made. Written treatment recommendations will be returned along with all submitted information. These recommendations are NOT to be considered prescriptions or orders. Responsibility for making treatment orders or medication orders will remain with the local health director or his/her designee.
B) DTC will continue to welcome all requests for clinical consultation from private providers. There is no current requirement that DTC review the management of all TB cases in the state. Therefore, to avoid confusion, films on privately managed patients should be submitted only at the request of the treating physician or by the public health nurse after consultation with this office.
C) Only films obtained for approved indications, as listed in Section IIB, should be submitted to this office for interpretation. Films submitted which do not meet the criteria outlined above will be reviewed, but returned without written interpretation or recommendations. Any significant findings noted during this review will, however, be communicated to the district. The district will be informed that the film(s) in question were not indicated. These films, including those obtained at the patient’s expense, should be submitted by the patient or health district to an appropriate radiologist for interpretation.
V. Policy Implementation
Responsibility for obtaining access to chest radiography services will rest with the local health district. In the past, DTC found it convenient to enter into contracts with local radiography vendors. These contracts ended on December 31, 2000 and were not renewed. The decision to renew or renegotiate with a local vendor will be left to the discretion of each district. DTC encourages each district to negotiate a fixed price for a one or two view chest examination with interpretation that matches the Medicaid rate.
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In the first year of this new program (i.e. January 1-December 31, 2001), DTC reimbursed local health districts for the cost of chest radiograph and interpretation for films meeting criteria IIB at a rate per eligible study of $30 for a single view and $35 for two views. Effective January 1, 2002, the rate of reimbursement reverted to the prevailing Medicaid reimbursement rate for the radiograph with an interpretation. DTC will reimburse at the 2002 Medicaid rate which is Single View $19.81 and Dual View $25.69. Please note that the 2002 rate is higher than the current Medicaid reimbursement rate.
Procedure for Obtaining Reimbursement for Eligible Chest Radiographs 
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