G9359 TB Screen Clearance HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS G9359: TB Screening and Clearance Prior to Biologic Therapy

HCPCS Level II code G9359 documents the completion of a tuberculosis (TB) screening process—either a documented negative screen or a managed positive screen with additional evidence demonstrating TB is not active—before initiating a biologic immune response modifier. Nationally, this code signals adherence to infection-screening protocols intended to reduce the risk of reactivating latent or undiagnosed active TB when prescribing immunosuppressive biologics.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare and Medicare. Readers will find a concise explanation of the clinical context for code use, typical sites of service, and which payers commonly recognize the code. The publication outlines billing and documentation expectations, common modifiers associated with outpatient pre-treatment services, and where payers may require supporting evidence in the chart.

The piece also summarizes benchmarks and policy updates relevant to pre-biologic infectious disease screening, clarifies clinical documentation elements that support code assignment, and points readers to areas where policy variation commonly occurs across commercial and public payers. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9359HCPCS Level IItuberculosis screeningbiologic therapy clearancepre-treatment evaluationinfectious disease screeningoutpatient servicesmedication safety

Billing Code Overview

HCPCS Level II code G9359 documents a negative or managed positive tuberculosis (TB) screen with further evidence that TB is not active prior to treatment with a biologic immune response modifier. This code is used to record that appropriate TB screening and follow-up evaluation have been completed and that active TB disease has been excluded before initiating biologic immunosuppressive therapy.

Service type: Pre-treatment infectious disease screening and clearance for initiation of a biologic immune response modifier
Typical site of service: Outpatient clinic or specialty physician office where biologic therapies are evaluated and prescribed

Clinical & Coding Specifications

Clinical Context

A 45-year-old patient with moderate to severe rheumatoid arthritis is being evaluated prior to initiation of a biologic immune response modifier (e.g., a TNF inhibitor). The clinician documents a history, reviews risk factors for tuberculosis (past exposure, prior TB infection, country of origin, immunosuppression), and obtains a TB screening test (interferon-gamma release assay or tuberculin skin test) and a chest radiograph. Results show either a documented negative TB screen or evidence of a prior positive TB test with subsequent evaluation (negative chest x-ray, no clinical signs of active disease, and treatment for latent TB completed or considered not active). The practice documents the negative or managed positive TB screen and records additional evidence excluding active tuberculosis prior to biologic therapy. Typical workflow: pre-biologic visit with history and risk assessment, ordering and review of TB test(s), chest x-ray if indicated, specialist or infectious disease consultation if positive, documentation of treatment or monitoring plan, and final clearance for biologic initiation. Typical site of service: outpatient clinic, specialty rheumatology or dermatology office, infusion center evaluation, or pre-treatment screening visit.

Coding Specifications

Modifier	Description	When to Use
`22`	Unusual procedural services	When documentation supports substantially greater work than usual for pre-treatment screening visit review and extensive documentation of TB evaluation.

HCPCS G9636: Health-Related Quality of Life Not Assessed or Declined

HCPCS-G0504-PSYCHIATRIC-COLLABORATIVE-CARE-MANAGEMENT-ADDITIONAL-30MIN

HCPCS G0504: Psychiatric Collaborative Care Management, Additional 30 Minutes

HCPCS-G0313-IMMUNIZATION-COUNSELING-UNDER-21-16-30-MINS

HCPCS G0313: Immunization Counseling for Patients Under 21, 16–30 mins

HCPCS-G8694-LEFT-VENTRICULAR-EJECTION-FRACTION-LVEF-40-OR-LESS-LVSD-MODERATE-SEVERE

HCPCS G8694: Left Ventricular Ejection Fraction ≤40% or Moderate–Severe LVSD

HCPCS-G9277-DAILY-ASPIRIN-OR-ANTIPLATELET-DOCUMENTATION

HCPCS G9277: Documentation of Daily Aspirin or Anti-Platelet Use or Exception

HCPCS-G6054-METHSUXIMIDE-ANTICONVULSANT-MEDICATION

HCPCS G6054: Methsuximide, Anticonvulsant Medication

HCPCS-G0432-HIV-EIA-SCREENING

HCPCS G0432: HIV-1/HIV-2 Antibody Screening by EIA

HCPCS-G9203-HEPATITIS-C-RNA-TESTING-PRE-TREATMENT

HCPCS G9203: Hepatitis C RNA Testing Documented Within 12 Months

HCPCS-G9153-MAPCP-PHYSICIAN-INCENTIVE-POOL

HCPCS G9153: Mapcp Demonstration Physician Incentive Pool

HCPCS-G9228-CHLAMYDIA-GONORRHEA-SYPHILIS-RESULTS-DOCUMENTED

HCPCS G9228: Chlamydia, Gonorrhea and Syphilis Screening Results Documented

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`207RC0000X`	Rheumatology	Rheumatologists commonly perform pre-biologic TB screening and documentation.
`207N00000X`	Dermatology	Dermatologists prescribing biologics for psoriasis conduct TB screening prior to therapy.
`208000000X`	Infectious Disease	Infectious disease specialists evaluate and manage positive TB tests and latent TB treatment decisions.
`207L00000X`	Allergy & Immunology	Allergy/immunology specialists involved when biologics affect immune response and screening is required.
`261QM1300X`	Radiology (Diagnostic)	Radiologists interpret chest radiographs used as part of TB exclusion prior to biologic initiation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z79.1`	Long term (current) use of antibiotics	Relevant when documenting prior or ongoing latent TB treatment as part of pre-biologic evaluation.
`Z11.1`	Encounter for screening for infectious and parasitic diseases; tuberculosis	Used for encounters focused on TB screening prior to immunosuppressive therapy.
`Z22.7`	Carrier of other bacterial diseases (e.g., tuberculosis carrier)	Applied when a patient is a known latent TB carrier requiring documentation before biologic therapy.
`B90.9`	Sequelae of tuberculosis, unspecified	May be used when prior treated TB is documented and considered in clearance decisions.
`M05.9`	Rheumatoid arthritis with rheumatoid factor, unspecified	Example underlying diagnosis prompting biologic therapy and need for TB screening.
`L40.0`	Psoriasis vulgaris	Example dermatologic condition for which biologic initiation requires TB screening.
`D86.0`	Pulmonary sarcoidosis	Relevant as a differential when evaluating chest imaging prior to biologic therapy.
`Z79.899`	Other long term drug therapy	Used when documenting other chronic therapies that affect infection risk and pre-treatment evaluation.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`86580`	Skin test; tuberculosis, intradermal (e.g., tine test)	Performed as an initial TB screening method prior to biologic therapy.
`86480`	Interferon-gamma release assay (e.g., Quantiferon-TB Gold)	Blood test commonly used for TB screening before starting biologics; often ordered and reviewed with documentation.
`71020`	Radiologic examination, chest; single view, frontal	Initial chest radiograph to exclude active pulmonary TB when screening is positive or risk is elevated.
`71046`	Radiologic examination, chest; 2 views, frontal and lateral	More complete chest radiograph used when clinical suspicion requires additional imaging.
`99499`	Unlisted evaluation and management service	Occasionally used when pre-treatment documentation does not fit standard E/M categories; documentation must support service billed.

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