Part B Insider (Multispecialty) Coding Alert

Published on Wed Aug 26, 2009 PDF

You'll get less pay for low complexity drug screen.

This winter a pair of G codes may replace CPT drug screen codes that paid you the same regardless of the test's complexity.

CMS is about to put an end to an unfair pricing practice. CPT lacks a distinct code for drug screen kits. Therefore, labs that perform a low-complexity test waived under the Clinical Laboratory Improvement Amendments (CLIA) currently garner the same pay as labs that perform a high-complexity drug screen on a manual or automated chemistry platform.

Problem: The following two codes are the only ones that labs currently have to bill for drug screens:

• 80100 -- Drug screen, qualitative; multiple drug classes chromatographic method, each procedure

• 80101 -- ... single drug class method (e.g., immunoassay, enzyme assay), each drug class.

Currently, Medicare pays $21.23 for 80100 and $20.11 for 80101 on the clinical lab fee schedule (national limit amount). CLIA-waived labs that use a low-complexity drugscreen test kit currently report 80101-QW (CLIA waived test).

"Kits that screen for 10 drug classes could mean the lab takes in more than $200 -- a generous payment for a test that the lab performs as a single procedure to screen for multiple drug classes," says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

CMS proposes to create two new G codes to replace 80100 and 80101 for Medicare patients starting in 2010:

• GXXX1 -- Drug screen, qualitative; multiple drug classes, any method, each procedure (e.g. multiple drug test kit)

• GXXX2 -- Drug screen, qualitative; single drug class method, (e.g. immunoassay and enzyme assay), each drug class.

"The new codes allow you to distinguish between drug test kits and chemistry analyzers that separately assess different drug classes." Dettwyler says.

GXXX1 appears to be the only code that labs would be able to use for a qualitative drug screen using a test kit that screens for multiple drugs with one procedure. "Presumably, CMS will price GXXX1 to limit payment for drug test kits," Dettwyler says.

Because GXXX2 has the same definition as 80101, watch to see if CMS drops the 80101 payment amount from the fee schedule, requiring you to use GXXX2 for payment instead.

"If you bill for drug screens, be sure to check fee-schedule payment amounts before 2010, because there may be some surprises," Dettwyler cautions.

CMS received industry input during the July 14, 2009 public meeting for the new codes. You can find CMS's proposed payments at www.cms.hhs.gov/ClinicalLabFeeSched by early September, and you can make comments on the recommended pricing until Sept. 18, 2009.

CMS will post final payment determinations on the same website in Oct. 2009, according to CMS contact Glenn McGuirk.

Expect crosswalk: Although payment method for codes can be either crosswalk -- paying at the same rate as a comparable existing code -- or gap-fill -- pricing a code based on analysis of annual carrier payment rates -- almost all presenters at the public meeting recommended crosswalks for the new codes.