As drug abuse reaches crisis levels for many communities across the country, accurate and reliable toxicology testing has grown more critical in the public health arena.  With lives in the balance, newer and better testing technologies will be required to meet this challenge, and that will, of course, have a downstream impact on laboratory billing practices.

But there is more insidious hurdle that toxicology laboratories must clear.  They need to stay in business.  And in that arena, they face a unique set of challenges.  When it comes to billing, toxicology is one of the most byzantine and downright confusing sub-specialties of clinical laboratory.  And much like the substance abuse epidemic that fuels demand, it seems to be getting worse.  For the last three years, there has been a state of near-constant change in toxicology CPT codes (or HCPCS codes).  The dizzying pace of change has depressed revenues for many providers, as many simply lack the man-hours and/or skills & resources to make rapid and repeated adjustments to their laboratory billing practices.

They say the only permanent thing in life is change.  And here is some solid evidence of that. Below is a quick history of the rapid-fire changes occurring over the last 3 years.

2015

In 2015, there was a fundamental shift as commonly used laboratory billing codes which covered the most basic drug test procedures, including the qualitative code 80101, and the quantitative codes 80154, 82145, 82520, and 83925, were dropped.  Subsequently the AMA and CMS issued competing sets of billing codes, which compounded the change by adding complexity.  For qualitative testing, CMS introduced G0431 and G0434, while the AMA introduced lab codes 80300-80304.  On the quantitative side, CMS began using codes G6030-G6057 while the AMA introduced a competing set for the same procedures with codes 80320-80379.

Subsequent to the issue of these new codes, Medicare chose to avoid the AMA codes based on rationale that the CMS method was less likely to result in substance abuse.  This led to more confusion in the landscape as some commercial carriers were accepting Medicare G codes and some were accepting 80300’s, while still others were accepting both. There were even a few commercial carriers that switched mid-year, thus making a second major shift in less than a year.  Meanwhile, Medicaid claims were all over the map, with Medicaid taking both the AMA and CMS codes.

2016

In 2016, CMS took an about turn by eliminating G0431 and G0434 laboratory billing codes, which had just been introduced a year earlier.  They then added qualitative billing codes G0477, G0478, and G0479, for laboratory testing for any number of drug classes, in which the tests are distinguished by reading method (direct observation of dipsticks card, etc., indirect observation of same assisted by instruments, or by instrumented chemistry analyzers).  And finally, they created the quantitative toxicology billing codes G0480, G0481, G0482, and G0483, which were for tests designed to identify individual drugs for 1-7, 8-14, 15-21, or 22 or more drug classes, including metabolite(s), respectively

2017

In 2017, CMS again reversed themselves, deleting the qualitative codes G0477, G0478, G0479, which were just introduced the year before (2016) and replacing those with codes 80305-80307.  These new codes were functionally identical to the old ones with the exception of adding a few more instrumented chemistry analysis methods.  In addition, CMS eliminated the separate validity testing codes 84311, 83986, 82570, whose functions were subsumed under other codes.

Confused?  It’s no wonder if you are.  As we near the end of 2017, it is probably fair to say that a majority of toxicology labs have been exposed to a real risk of a significant shortfall in both billing and collections, just by the sheer volume of changes.

Future Outlook

Like many sectors of the U.S. economy, the health care system is addressing the advance of technology, which is occurring at a breathtaking (and ever increasing) rate.  Within healthcare, diagnostics is perhaps the most sensitive area to these advances, given breakthroughs in data analysis and artificial intelligence which can (and will) be game-changers going forward.  The recent and rapid changes in coding are a reflection of this phenomenon.  When viewed through this lens, it seems inevitable that the changes will continue to come with even greater frequency.  The challenge for clinical laboratories will be to keep abreast of this change and be ready to react.

What to Watch For

If any of the above comes as news to you, and you have that sinking feeling that you may have left money on the table due to the complexity of toxicology billing…you may be correct.  And you are not alone.  A toxicology lab comes with and unique set of challenges with regard to billing.

Will it get better?  Doubtful.  As 2018 looms, there does not seem to be any reason to think the pace of change will slow down.  In fact, 2018 may prove to be even more challenging with the upcoming Protecting Access to Medicare Act of 2014 (PAMA) that is scheduled to take effect January 1 and will likely significantly reduce clinical laboratory billing reimbursement.  More information will be forthcoming in a subsequent article on this subject.

Going forward, the task of getting the most out of your toxicology laboratory billing will require not only special diligence, but also the application of effective tools and problem-solving skills.  To stay out in front of these trends and maximize collections, here are a few of the key aspects of your billing practices that should be addressed:

  • Resources to follow-up on individual claims, appeals, provide medical necessity, etc.
  • Ability to perform systematic analysis to find problem payers
  • Payer contracting strategy, enrollment, and negotiation
  • Deployment of analytics tools to help identify problems that need attention
  • Appeals software that helps collectors win more claims
  • Identifying payer rules to predict and prevent problems

Toxicology laboratory billing is, and will likely continue to be in the near time, one of the most volatile specialties when it comes to medical coding.  If you use a billing company, you should demand these things as part of your service package.  If you don’t currently address these issues, your margins may continue to shrink in a competitive landscape.

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