Summary & Overview

HCPCS G9932: Documentation of Missing TB Screening Records

HCPCS Level II code G9932 denotes documentation of a patient's reason for lacking records of a negative or managed positive tuberculosis (TB) screen, for example when a patient fails to return for Mantoux (PPD) skin test evaluation. Nationally, clear documentation of missed or incomplete TB screening is important for infection control, public health reporting, and continuity of care across outpatient and community health settings. Proper use of this code helps health systems and payers track gaps in screening and supports accurate medical records.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of the code's clinical context, common sites of service, and what the code represents in administrative workflows. The publication also outlines likely uses for billing and recordkeeping, typical documentation expectations, and where the code sits in TB screening and follow-up processes. Data not available in the input for associated taxonomies, ICD-10 pairings, and payer-specific reimbursement details.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9932HCPCS Level IITB screeningtuberculosisdocumentationoutpatientprimary carepublic healthscreening follow-up

Billing Code Overview

HCPCS Level II code G9932 documents the patient's reason(s) for not having records of a negative or managed positive tuberculosis (TB) screen. The description specifies examples such as when a patient does not return for Mantoux (PPD) skin test evaluation. This code captures documentation explaining absence of TB screening results in the medical record.

Service Type: Documentation / Screening follow-up

Typical Site of Service: Outpatient clinic or primary care setting where TB screening is ordered or followed up, including public health clinics and community health centers.

Data not available in the input for associated taxonomies, ICD-10 diagnoses, and related codes.

Clinical & Coding Specifications

Clinical Context

A patient presents to a primary care clinic for routine care or occupational health clearance and lacks documentation of a negative or managed positive tuberculosis (TB) screening. The clinic attempted to perform a Mantoux tuberculin skin test (TST) but the patient did not return for the 48–72 hour reading, or prior TB screening records from another facility are unavailable. The provider documents the patient’s reason(s) for not having verifiable TB screening results (for example, patient did not return for TST reading, lost prior records, or the patient declines testing). This documentation is entered into the medical record to support medical necessity for deferred testing, to guide next steps (e.g., offer IGRA blood test, reschedule TST, or begin symptom surveillance), and to meet program or payor requirements for record completeness. Typical workflow: intake staff review immunization/infectious disease record; clinician or nurse counsels patient on TB screening options; attempt is made to place TST or order IGRA; if no documented negative or managed positive result exists, clinician documents the specific reason(s) for absence of record and any plan; coder assigns G9932 to indicate documentation of reasons for not having documented negative or managed positive TB screen. Typical site of service is outpatient primary care, occupational health clinics, public health clinics, or pre-employment clearance sites. Typical patient scenarios include employees or students requiring TB clearance who miss the TST reading visit, patients with prior positive TST with no documentation of management, or individuals who decline or cannot complete testing due to scheduling, travel, or acute illness.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when additional documentation supports substantially greater work performed related to counseling or extensive documentation about TB screening absence.
`23`	Unusual anesthesia	Not typically applicable; include only if unusual anesthesia was required for a concurrent procedure.
`52`	Reduced services	Use when the service was partially reduced (e.g., TST placed but not completed) and documentation supports reduced service.
`53`	Discontinued procedure	Use if a planned related procedure (e.g., TST placement) was started but discontinued for legitimate medical reasons.
`54`	Surgical care only	Rarely applicable; include only when responsibility for related surgical procedure is transferred.
`55`	Postoperative management only	Rarely applicable; include only when post-op care is billed separately in relation to a procedure.
`56`	Preoperative evaluation only	Use if documentation reflects only pre-procedure evaluation prior to a TB-related procedure that was not completed.
`62`	Two surgeons	Not typically applicable; include only in complex multi-surgeon encounters unrelated to standard TB documentation.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Not typically applicable for TB documentation.
`CO`	Skilled nursing facility consolidated billing exclusion	Use when billing rules require this modifier for certain facility payor arrangements.
`CQ`	Service furnished by a registered dietitian or nutritional professional	Not typically applicable.
`FX`	Service provided by a resident under primary care exception	Use when a resident provides the service under the primary care exception and payor requires `FX` to indicate absence of teaching physician.
`FY`	Service furnished by a resident not under primary care exception	Use when resident provided service but teaching physician was present and payor billing rules require `FY`.
`QK`	Medical direction of two, three, or four technicians/qualified health professionals	Use if the visit included medically directed services requiring this team modifier per payor rules.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary providers who document TB screening status and reasons for absent results.
`208D00000X`	General Internal Medicine	Common site for adult routine screening and documentation of TB test absence.
`366A00000X`	Occupational Medicine	Frequent setting for pre-employment TB clearance and documentation of missing results.
`334400000X`	Public Health Clinic/Community Health	Clinics that document screening gaps for reportable disease control programs.
`163W00000X`	Infectious Disease	Specialists consulted for complex or managed positive TB cases lacking documentation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z11.1`	Encounter for screening for respiratory tuberculosis	Common reason for TB screening; documentation of absent results is directly relevant.
`Z02.89`	Encounter for other administrative examinations (e.g., pre-employment physical)	TB screening often required for administrative clearance; missing results are documented with `G9932`.
`Z20.9`	Contact with and (suspected) exposure to communicable disease, unspecified	Used when exposure risk prompts screening and documentation is required if no result is available.
`Z71.1`	Person with feared health complaint in whom no diagnosis is made (counseling related)	May be used when counseling or refusal leads to absent TB test documentation.
`R68.89`	Other general symptoms and signs (e.g., acute illness delaying testing)	Acute symptoms that delay testing and lead to lack of documented result are documented as reason for absence.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`86580`	Skin test, tuberculosis; intradermal (Mantoux), including interpretation and report	Performed when a TST is placed and read; absence of a reading may prompt `G9932` documentation explaining why no negative/managed positive result is available.
`86480`	Interferon gamma release assay (e.g., Quantiferon)	Alternative diagnostic test ordered when TST reading is missed or prior records are unavailable; documentation of reason for no TST result supports ordering IGRA.
`99401`	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (approximately 15 minutes)	Counseling about TB testing options and documentation of patient refusal or inability to complete testing can be billed as preventive counseling when applicable.
`99402`	Preventive medicine counseling (approximately 30 minutes)	Use for more extensive counseling and documentation related to TB screening decisions and reasons for missing results.
`99395`	Periodic comprehensive preventive medicine reevaluation and management of an individual (18–39 years)	Routine preventive visit where TB screening status is reviewed and `G9932` is documented if no record of negative/managed positive TB screen exists.