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Specimen Validity and Urine Drug Tests Under Review

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  • February 20, 2018
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Specimen Validity and Urine Drug Tests Under Review

A specimen validity test performed on the same day as a urine drug test for the same person should be a rare occurrence because specimen validity testing is included in the description of HCPCS Level II codes for urine drug tests. Billing both tests separately is like double-dipping. And yet, Medicare paid 4,180 clinical laboratories and physician offices a sum of $66.3 million for both such tests billed between 2014-2016, according to an Office of Inspector General (OIG) February 2018 report.
The Centers for Medicare & Medicaid Services (CMS) agreed with the OIG’s recommendations to:

  • Recover the $66.3 million in identified improper payments; and
  • Strengthen its system edits to prevent improper payments for specimen validity tests.

CMS has already taken several measures to curb noncompliant billing, including:

  • In 2015, CMS issued new requirements in its National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services (chapter 10, section E) which states: “Providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing.”
  • In 2016, CMS created new HCPCS Level II codes for certain urine drug tests, including specimen validity testing in the descriptions.
  • In April 2016, CMS implemented NCCI automated system edits to identify and prevent improper payments for specimen validity tests billed in combination with urine drug tests.

These measures have greatly reduced improper payments (from approximately $37 million in 2014 to $4.3 million in 2016), but improper payments continue.

Understand the Tests

Coders would do well to familiarize themselves of the purpose for the laboratory tests their coding. This will help recognize redundant billing.
Urine drug testing provides objective information to assist providers in identifying the presence or absence of drugs or drug classes in the body or to identify the specifications quantity of a drug or drug class present in the body.
Specimen validity testing is used to analyze a urine specimen to ensure that it is consistent with normal human urine. It may be used to diagnose certain conditions such as a urinary tract infection, kidney stones or rheumatoid arthritis.

Understand Medicare Coverage

Plain and simple: When specimen validity testing is used to determine whether a specimen is adulterated or tampered with, rather than to manage a patient’s specific medical problem, it is not a separately billable service under Medicare. Providers performing validity testing on urine specimens also utilized for drug testing should not separately bill the validity testing.

Take Corrective Actions

Practices that bill these lab tests should expect Medicare claims reviews. Rather than wait for the ball to drop, it would be wise for labs and physician offices to:

Medical coding books

  • Perform internal audits to identify improper payments for this test combination;
  • Refund improper payments; and
  • Correct improper billing practices.
Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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