The following is written by Leslie Johnson CCS-P, CPC, director of coding and education for Medi-Corp.
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As you might be aware, CMS does not recognize the 80101/80102 codes any longer. HCPCS code G0430 was deleted and was actually broken out into new categories with G0431 and G0434 more accurately describing the work involved in collecting and testing the urine samples.
In 2011, G0431's descriptor was changed to: "Drug screen, qualitative; multiple drug classes by high complexity test method (e.g. immunoassay, enzyme assay), per patient encounter."
G0434 has this for the descriptor: "Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter."
For discussion's sake, I looked up the term "high complexity test method" to better understand what CMS was looking for. On this CMS webpage (pdf), pages four and five will describe the testing methods and explain the rationale for deleting the older codes and creating new ones (from 2009/2010).
Most notably, you'll find this definition to be very helpful:
"CMS recommends changing the descriptor for this test code to more accurately reflect the high complexity confirmatory drug screening tests performed in the laboratory setting. By setting the payment at a multiple of five (5) times the price of testing for one drug of abuse, we are recognizing that multiple drugs are often tested through one specimen and that the high complexity tests that are performed in the laboratory setting require more resources than the simple dipstick test kit tests performed outside the laboratory setting."
CMS desired for this code to be used within a laboratory setting, not within a physician's office which is why they capped it. The payment for this single code reflected 5x the amount they expected to pay for a single test, which was to supposed to have been reported with the original 80101/G0430, but wasn't. This is one of the reasons for what appears to be a loss of revenue for doing the same amount of tests, but being able to report it only a single time now. It also explains why CMS deleted this code and then added the new code G0434. If you check the CPT book, the words: "each procedure" found in the CPT descriptor for 80101 and 80104 make it impossible for CMS to recognize these codes for payment and keep to their original objective.
In 2011, they took the description and rationale from G0430 (2009), deleted the code, and moved the descriptor to G0434 (2011):
"CMS created this new test code based on a programmatic need to accurately reflect both CLIA waived and moderate complexity testing for drugs of abuse per patient encounter rather than per dipstick test. As a result, CMS also recommends changing the descriptor to more accurately reflect this goal. This reflects the fact that in any given patient encounter, no matter how many drugs of abuse tests are performed and no matter whether these tests are CLIA waived (simple dipstick test kit) or moderate complexity (reader outside the laboratory setting), proper billing would be one time per patient."
CMS will pay for only a single test per patient encounter, regardless of the number of drug classes tested. If your practice is doing these tests in a CLIA-waved setting, the code should be G0434-QW x 1 unit. If done in a laboratory setting, depending on how the test is performed, it may be either G0431 x 1 unit or G0434 x 1 unit.
For the State of New York, click here to access the webpage for Medicare's LCD on Qualitative Drug Screening #L28145.
Contact Leslie Johnson at ljohnson@medi-corp.com. Learn more about Medi-Corp.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Read more from Leslie Johnson:
- Update: AMA Clarifies Fluoroscopy Coding Guidance
- Coder's Guide to Epidurogram (CPT 72275)
- Proper Coding of Nerve Block With EMG Guidance Requires Careful Review of OP Report