It seems that toxicology billing is not going to get any simpler.  Already this year, the CMS has reversed themselves for the second year in a row. The qualitative codes G0477, G0478, G0479 were deleted, after being introduced in 2016.  Those codes were replaced with 80305-80307.  These new codes were essentially the same as the old ones, other than the addition of a few more methods of instrumented chemistry analysis. CMS also eliminated the separate validity testing codes 84311, 83986, 82570, the functions of which were rolled up under other existing codes.

Medicare / CMS

Presumptive / qualitative test Crosswalk 2016 to 2017

2016 AMA          2016 CMS           2017

80300 G0477 80305
80300 G0478 80306
80301, 80302, 80303, 80304 G0479 80307

 

G0477, Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 80305 Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipstick, cups, cards, cartridges) includes sample validation when performed, per date of service.
G0478, Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, (e.g., immunoassay) read by instrumented assisted direct optical observation (e.g., dipstick, cups, cards, cartridges) includes sample validation when performed, per date of service.
G0479, Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service .

 

CMS reimbursement increases

Overall, reimbursement rates have shown increases of widely varying degrees across the board. Increases were marginal for screening tests, showing less than 1% increase.

Presumptive (aka screening) tests

CPT 2017 2016 Change
80305 14.96 14.86 0.7%
80306 19.95 19.81 0.7%
80307 79.81 79.25 0.7%

 

For confirmation tests, on the other hand, reimbursement has increased significantly for 2017.  Average reimbursement figures show a 30% increase, with the lowest level panel increasing by as much as 47%.

Confirmation (aka definitive) tests

CPT 2017 2016 Change
G0480 117.65 79.94 47.2%
G0481 160.99 122.99 30.9%
G0482 204.34 166.03 23.1%
G0483 253.87 215.23 18.0%

 

Important New Code: G0659

A new code for 2017, G0659, is designed for drug tests that do not meet new, more stringent calibration standards for each drug being tested in a panel. The language reads as follows:

G0659: (Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes).

For many labs, the standard large panel tests they have been performing historically will now be considered below standard in accuracy and therefore would be reimbursed at the lower drug-screening rate of  $79.  You won’t be able to bill on the old codes (G0480-G0483) if the new and more exacting calibration standards are not met.

If you are not currently meeting the calibration standards, the financial impact on your lab could be significant.  Your reimbursement could easily drop from as high as $250 down to $79 for these tests.

Which codes to bill?

So, should you always bill 80305-80307 and G0480-G0483Unfortunately, the answer is no.  Some payers are still using older codes, others are accepting both sets of codes. You need know the payer policies, although this can be very challenging.

As a case in point, some payers have rules that apply to maximum number of samples, while others have a maximum number of tests, and some of both sets of limitations.  This could be in addition to the fact that they accept both sets of codes.  How to choose amidst so much complexity?  In some cases those rules make choosing the “correct” codes seem completely counterintuitive.

CIGNA, for example accepts both presumptive code sets.  Is there one set that is better to bill?  It depends on the nature of the test(s).  CIGNA policy notes a maximum of 8 units for confirmation testing per date of service.  Historically, if more than 8 units billed, CIGNA used to just down-code and only pay for 8.  Now, they will deny the entire claim.  This introduces enormous complexity in your lab operations as well as with the referring provider, because if a physician orders more than 8 classes, they will all be performed and resulted.  And the requisition, results, and billing must all match.

The bottom line is that you need to know every single payer’s policies, which code or codes they accept, and which is better to bill to maximize your reimbursement not just on that individual sample, but for the year over often many samples.

Conclusion

It is more critical than ever to choose the correct codes when billing.  These choices can make a huge difference in avoiding denials of service and keeping your accounts receivable from ballooning out of control.   And now more than ever, choosing the right codes can have a big impact on your revenue.  You need to do your homework and choose codes wisely, but as we have seen, you also need to be prepared to change on a dime.

If you outsource your billing, you need a company that stays up to date with constantly changing payer policies, communicates those changes, and works with the lab to find solutions.  But more than that, you need a real-time flow of data analysis to spot and keep up with new changes in payer policies.

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