Revenue Cycle Insider

Question: We are an independent laboratory that has been experiencing denials for our toxicology services billed with 80307 and G0480-G0483. The ordering provider is billing for their services for patients in addiction treatment/detox facilities using such codes as S0201, S9480, H0015, and H0035. What can we do about this?

AAPC Forum Participant

Answer: The problem here is that the toxicology codes your lab is billing — 80307 (Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers… includes sample validation when performed, per date of service) along with G0480 (Drug test(s), definitive… per day; 1-7 drug class(es), including metabolite(s) if performed), G0481 (8-14 drug class(es), including metabolite(s) if performed), G0482 (15-21 drug class(es), including metabolite(s) if performed), and G0483 (... 22 or more drug class(es), including metabolite(s) if performed)— are bundled into the codes the ordering provider is billing. Here’s a look at the codes the provider wants to bill:

• S0201 (Partial hospitalization services, less than 24 hours, per diem)
• S9480 (Intensive outpatient psychiatric services, per diem)
• H0015 (Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education)
• H0035 (Mental health partial hospitalization, treatment, less than 24 hours)

These codes reflect per diem services for patients undergoing treatment for substance use disorders or detox crisis intervention in a residential setting. The codes include the cost of both presumptive and definitive drug testing.

While the bundles are not subject to National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits, they are usually subject to payer policies. For example, Horizon Blue Cross Blue Shield of New Jersey’s (Horizon BCBSNJ) Urine Drug Screening/Testing policy states “urine drug testing is included in any inclusive payment model such as per diem, case rate or bundled service arrangements.” Horizon BCBSNJ goes on to note that they allow 1 unit of presumptive testing (which includes 80307) and 1 unit of definitive testing (which includes G0480) “when performed on the same date of service” as per diem substance use disorder services. Additionally, “HCPCS codes G0481, G0482, and G0483 are not eligible for reimbursement” per Horizon BCBSNJ.

This means your lab should enter into a separate billing agreement with the billing provider for them to pay you directly for any toxicology testing your lab is performing for them and for which they are subsequently being reimbursed through their per diem service billing.

You should also ask the billing provider to verify whenever they are ordering lab services for a patient who is not subject to any inclusive per diem billing they are providing. In such cases, your lab services would not be regarded as being bundled and you may be able to bill the patient’s insurance directly for your toxicology testing. But remember, the ordering provider must provide clinical documentation proving medical necessity for the test(s) being requested.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC