Don’t Confuse Toxicology Screenings with Confirmations

Don’t Confuse Toxicology Screenings with Confirmations

Here is what you need to know about recent changes that will help you differentiate the two.

The past few years have brought changes in CPT® and HCPCS Level II coding for presumptive toxicology screenings (screens) and definitive confirmations (confirms). Here’s what providers, billers, coders, and auditors need to know about these developments.

Research and Review

Verify the policy changes for your payers, as summarized in Table A, to avoid unnecessary denials.

Table A: Payer Policy Changes

Medicare Effective 2018: Requirements allow for both a singular screen and singular confirm on the same date of service (12 of each, per 12-month period)
Aetna No changes in 2018; effective since 2016: Requirements allow for eight screens and eight confirms, per rolling 12-month period
United Healthcare Effective 2018: Requirements allow for 12 screens and confirms each, per year (down from 18 per year in 2017)
Cigna No changes in 2018; effective in 2017: Requirements allow for 32 screens and 16 confirms per year; considers up to G0481 medically necessary (will not reimburse G0482, G0483); any more than eight drug classes/confirms is considered not eligible for reimbursement
Humana No changes in 2018; effective in 2017: Requirements allow for 12 screens/confirms per year; considers G0480 medically necessary (will not reimburse G0482, G0483); any more than seven drug classes/confirms is considered not eligible for reimbursement

 

Focus on Big Changes

January 2018 saw a significant change in frequency guidelines, as well as reimbursement policy for Anthem Blue Cross Blue Shield. The reimbursement policy 0038 “Drug Screen Testing,” enforceable Jan. 1, can be applied to both traditional Anthem plans and Medicare Advantage plans. The states affected by these new policies include California, Connecticut, Colorado, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, Virginia, and Wisconsin.

Here’s a summary of the critical modifications in reimbursement policy (Note: HCPCS Level II short descriptions were used to save on space):

  1. Screening can be done at the provider office; then, a confirm (only up to 14 drug classes, or G0480 Drug test def 1-7 classes, G0481 Drug test def 8-14 classes) can be sent out to a reference laboratory, if medically necessary.
  2. The independent reference laboratory CANNOT perform a screen and confirm on the same patient for the same date of service (either a screen or a confirm should be ordered).
  3. Confirms for 21 or more drug classes (G0482 Drug test def 15-21 classes, G0483 Drug test def 22+ classes) should be ordered only when medically necessary. These require full chart notes to support the medical necessity documentation. These must also be paper billed by the independent reference laboratory with supporting documentation.
  4. Oral/Saliva toxicology is not deemed medically necessary and is not covered.

The clinical guideline CG-LAB-09 “Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain,” effective Jan. 1, highlights medical necessity requirements, as well as examples of screens and confirms not medically necessary.

The guideline addresses drug testing using urine, blood, saliva, sweat, or hair samples in the outpatient setting. These tests are commonly performed for adherence monitoring of controlled substance use as part of chronic pain management for individuals undergoing treatment for opioid addiction and substance use disorder.

It’s important to know the medical necessity criteria for screens to verify compliance with treatment, to identify undisclosed drug use/abuse, or to evaluate aberrant behavior. The guideline allows up to 24 screens per year, beginning at the start of treatment, as part of a routine monitoring program for individuals who are:

  • Receiving treatment for chronic pain with a prescription opioid or other potentially abused medication; or
  • Undergoing treatment for, or monitoring the relapse of, opioid addiction or substance use disorder.
  • To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances; or
  • On initial entrance into a pain management program or substance use disorder recovery program.

Generally, drug screens detect whether there are drugs or drug classes present in a patient’s system during a patient encounter. These tests provide a positive or negative result for the presence of drug(s), but do not indicate specific levels.

The guideline also specifies these medical necessity requirements apply for confirms:

  • If the confirm was performed for a medically necessary reason; If the confirm was negative for prescribed medications, but positive for a prescription drug (which was not prescribed) with abuse potential, or positive for an illegal drug; If the confirm is supported by documentation specifying rationale for this quantitative test; and
  • If clinical documentation reflects how the results of the tests will be used to guide clinical care.

Examples of screens and confirms not medically necessary involve using blood, saliva, sweat, or hair. The use of reflex testing, standing orders, and blanket orders for confirm drug testing of urine or blood samples is considered not medically unnecessary in all circumstances.

Reimbursement Tips with Anthem

Providers can still perform screens in-house and order out G0480 or G0481 confirms to reference laboratories. Ordering out a confirm G0482 or G0483 requires full chart notes and paper billing to document the medical necessity of the test.

Providers cannot send out both a screen (80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service) and confirm to a reference laboratory with the same date of service. Anthem will deem only the screen (80307) as medically necessary. Providers should order either a screen or a confirm.

Resources

Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy
(Subject: Drug Screen Testing): www11.anthem.com/provider/noapplication/f0/s0/t0/pw_g319043.pdf?refer=ahpmedprovider&state=mo

Anthem Clinical UM Guideline (Subject: Drug Testing or
Screening in the Context of Substance Use Disorder and Chronic Pain):
www.anthem.com/medicalpolicies/guidelines/gl_pw_c166612.htm

Sonal Patel

Sonal Patel, CPMA, CPC, CMC, is a healthcare coding and compliance consultant at the law firm of Nexsen Pruet, LLC. She has over 10 years of experience in multi-specialty healthcare coding and auditing. She provides reimbursement investigations for Parts A and B providers. Patel delivers healthcare lawyers with strategies and analyses to overturn denials with private and government payers. She is a member of the Northbrook, Ill., local chapter.

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Sonal Patel, CPMA, CPC, CMC, is a healthcare coding and compliance consultant at the law firm of Nexsen Pruet, LLC. She has over 10 years of experience in multi-specialty healthcare coding and auditing. She provides reimbursement investigations for Parts A and B providers. Patel delivers healthcare lawyers with strategies and analyses to overturn denials with private and government payers. She is a member of the Northbrook, Ill., local chapter.

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