Tuesday, November 17, 2015

CPT 80300 through CPT 80377 - Clinical Laboratory Fee Schedule (CLFS) Update

procedure code and description

80300- Drug screen non tlc devices - Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (i.e., immunoassay) capable of being read by direct optical observation, including instrument-assisted when performed (i.e., dipsticks, cups, cards, cartridges), per date of service.

Blue Cross and Blue Shield of Oklahoma (BCBSOK) will continue to follow Medicare’s lead and will zero-price the CPT® drug testing codes (80300 – 80377).

With a few exceptions, BCBSOK’s billing guidelines for urine drug testing are intended to be consistent with those established by CMS for safety, accuracy and quality of diagnostic testing and will make use of the HCPCS G codes (G0477, G0478, G0479 for presumptive testing and G0480, G0481, G0482 and G0483 for definitive testing) that CMS established to replace the deleted 2015 HCPCS drug test codes.

All testing and services that share the same date of service for a patient must be billed on one claim. Split billing is a violation of network participating provider agreements.

CLIA Certification

Facilities and private providers who perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Therefore, any provider who performs laboratory testing, including urine drug tests, must possess a valid a CLIA certificate
for the type of testing performed.

Qualitative Drug Screen (Presumptive Drug Testing)

All of these codes include any number of drug classes, devices or procedures. Only one of the presumptive G codes may be billed per date of service.

Use G0477 for testing capable of being read by direct optical observation only. Test includes validity testing when performed and may be performed only once per date of service.

Use G0478 when test is read by instrument- assisted direct optical observation. Test includes validity testing when performed and may be performed only once per date of service.

Use G0479 when test is performed by instrumented chemistry analyzers (e.g. Immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, CHPC, GC mass spectrometry). Test  includes validity testing when performed and may be performed only once per date of service.

Qualitative or presumptive drug screening must meet medical policy criteria, including appropriate medical record documentation.

A major change in this section is the deletion of the Drug Screening services (Codes 80100, 80101, 80102, 80103, and 80104) and the replacement of them with new codes that more clearly define the drug class and the methodologies involved in the testing (80300, 80301, 80302, 80303, 80304).

Final Determinations

Codes 80300 through 80377  (63 codes)

Industry Recommendation: Various, from crosswalking to specific existing codes (e.g., G0434, G0431, etc.), to gapfilling.
CMS Recommendation: Delay in pricing.

Rationale: These codes represent various drugs of abuse testing codes, many of which are specific
to individual drug testing.

In the 2015 clinical laboratory fee schedule preliminary determinations file that we released to the public on October 9,2015, we proposed to not pay for new CPT codes for drugs of abuse tests. We stated our concern about the potential for over payment when billing for each individual drug test rather than a single code that pays the same amount regardless of the number of drugs that are being tested. Therefore, we recommended delaying pricing for these codes at this time, until further information and education is obtained.

Commenters have advised us that several of the tests reported by codes deleted by the CPT Editorial Panel were to be reported by the new codes that we are not recognizing. We continue to believe that we need additional time and input from the public to determine Medicare payment for drugs of abuse testing that will not lead to overpayment. Until such time, we believe that Medicare should not recognize the additional codes created by CPT for drugs of abuse tests. However, we agree with the commenters that there will not be sufficient codes available to bill for drugs of abuse tests if we finalize our proposal. For this reason, we are maintaining the 2014 status quo for 2015 and creating alphanumeric G codes to replace the 2014 CPT codes that are being deleted for 2015. For 2015, providers are to use these G codes in the same manner in which they used the corresponding CPT codes for 2014.

In addition, for some of the drugs of abuse testing codes, CPT did not delete the 2014 code
numbers, but revised the instructions or code descriptors in the 2015 CPT Manual. For billing
CLFS in 2015, we are instructing the public to use these codes exactly as they used them for 2014,
regardless of the 2015 instruction or code descriptor changes. The following are some examples of
the application of this policy:

• The prefatory language for the Therapeutic Drug Assay section of the CPT Manual changed between 2014 and 2015. In the 2014 CPT Manual, this section allows for testing urine specimens. In the 2015 CPT Manual, the section does not allow for urine testing. For 2015, bill Medicare according to the prefatory language that applied to the Therapeutic Drug Assay section of the 2014 CPT Manual.

• The procedure specific codes (chromatography, mass spectrometry, etc) for drug analytes
that are not specified elsewhere are in the Chemistry section of the 2014 CPT Manual.
The 2015 CPT Manual has prefatory and parenthetical language that instructs providers
to not use Chemistry section codes for drug screening tests (unless there is a specific analyte code) and refers them to the new CPT codes that we decided not to pay for in 2015. In one group of 4 codes, the descriptors have been changed to “non - drug.” For  2015, use the instructions in the Drug Testing section and Chemistry section of the 2014 CPT Manual and ignore the 2015 prefatory and parenthetical language, as well as the change in descriptors for CPT codes 82541, 82542, 82543, & 82544, that prohibit the use of CPT codes in the Chemistry Section for testing for drugs.

As we further consider coding and payment for these services in 2016, we will be looking to
balance beneficiary access with appropriate payment for medically necessary services under
the Medicare program.

HCPCS drug testing codes effective January 1, 2016

As you may know, CMS does not recognize the CPT codes 80300-80377 and 83992 for definitive and/or presumptive drug testing and had assigned Status Code "I"-Not valid for Medicare purposes-to those codes. CMS announced that effective January 1, 2016, it will use HCPCS' new "G" codes for "per day" presumptive and definitive drug testing.

Bundled Services and Supplies and Modifiers 59 and XE, XP, XS, & XU

Effective May 1, 2016, we are adding to Section 2 of our policy that CPT codes 82570 (assay of urine creatinine) and 83986 (assay ph body fluid nos) are considered incidental to, and not eligible for, separate reimbursement when reported with presumptive and definitive drug testing CPT codes 80300-80377 and 83992. Bypass modifiers will not override the edit, therefore the information is also included in our Modifiers 59 and XE, XP, XS, & XU reimbursement policy.

Durable Medical Equipment

When durable medical equipment (DME) is rented by a patient, the Health Plan allows rental up to the purchase price or a maximum 10 month rental period, whichever comes first. When a patient was previously covered by another health insurance policy and such other policy covered a portion of the DME purchase price or rental period, we will apply the previous policy’s allowed amount or rental months to our current purchase allowance or 10 month rental period, whichever comes first, when the DME item is procured from the same DME provider. This information may be found under the “Purchase/Rent to Purchase” section of our policy dated December 1, 2015.

As a reminder, our recent Network eUPDATE, “HCPCS drug testing codes effective January 1, 2016,” advised that we will be adding CPT codes for presumptive (80300-80304) and definitive (80320-80377 and 83992) drug testing to our always bundled services edit beginning with dates of service on or after March 15, 2016. Providers are reminded to use the new HCPCS “G” codes (G0477-G0483) when reporting presumptive and definitive drug testing services for dates of service on or after March 15, 2016.

Revision to the Laboratory Services Policy

The American Medical Association recently added new codes within the Pathology and Laboratory section of CPT codes 80300-80377. To align with the Centers for Medicare & Medicaid Services (CMS) guidance on the reporting of drugs of abuse testing, UnitedHealthcare will no longer reimburse CPT 80300-80377 until more definitive direction is received from CMS on how these codes should be paid. The change to the policy will become effective for claims with dates of service on and after June 1, 2015.

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