Payers Targeting 80101 Abuse for Drug Testing
Per AMA instructions, when coding for drug testing by any method other than chromatography for multiple drugs or drug classes, you should report 80104 Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure. If qualitative methods other than chromatography are used to test for a single drug only, you should report 80101 Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class.
In recent years, there has been confusion on proper coding when using a “kit” containing multiple dipsticks (or cassettes, cups, etc.), each of which is used to detect a different analyte. AMA’s CPT Assistant, December 2010, explains, “Kits are commercially available for 12 or more analytes. These test kits are…. effectively running multiple tests at once, in a single procedure, due to the test kit design.”
Proper coding when using such a “multiplex” test kit is a single unit of 80104—not multiple units of 80101. Payers in California and elsewhere have begun post-payment audits of provider claims, and are demanding repayment when multiple units of 80101 were reported, but where 80104 was appropriate. Improper payments have been substantial, in many cases equaling thousands of dollars, per claim.
Cutting the Confusion
Prior to 2011, qualitative testing of multiple drug classes in a single kit commonly was reported using multiple units of 80101. CPT® 2011 changed this with the introduction of 80104, which was created specifically “to describe a non chromatographic method wherein multiple drug classes were screened in a single procedure… more accurately reflecting the resources used in a multiplex test kit as compared to multiple runs using a single class methodology,” according to CPT Assistant (Dec. 2010).
The AMA’s CPT 2011 Changes: An Insider’s View further clarifies, “Code 80104 has been established to report a specific drug screen, qualitative analysis by multiplexed method for 2-15 drugs or drug classes (eg, multidrug screening kit).”
Be especially cautious when reporting multiple units of 80101, to be certain each unit represents (and documentation substantiates) a unique test, rather than the individual components of a single multiplex testing kit.
Finally, Medicare does not accept 80101 or 80104, and instead requires G0431 Drug screen, qualitative; multiple drug classes by high complexity test method (eg, immunoassay, enzyme assay) per patient encounter and G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter. Note that the Medicare codes specify “per patient encounter,” rather than per procedure or per analyte. For additional instructions, see MLN Matters® Number: SE1105 Revised.