Revenue Cycle Insider

Beware of Medicare’s definitive drug testing codes.

Purpose, procedure, payer, and proof ­— align these four items on your drug-test claims and you can ensure accurate coding. Read on for details to help you capture the pay your lab deserves.

Purpose: Understand Why the Provider Orders the Test

Physicians may order drug assays to fill various clinical needs, such as screening for substance abuse, monitoring medical treatment regimens, or testing for therapeutic drug levels. Knowing the reason for the test could direct you to a host of different codes in the following categories:

• Screening: Evaluating a specimen such as urine for the presence of an array of substances would qualify as a screening test. You’ll sometimes see these referred to as “qualitative” or “presumptive” tests. These tests typically report the specimen as positive or negative for the tested drugs or drug class(es) without quantification.

A “drug class” is a collection of drugs that have similar chemical structure, the same mode of action, and/or serve the same clinical purpose. A presumptive test does not specifically identify a drug within a tested drug class.

• Identification: Evaluating a specimen to identify a specific analyte and/or measure the level of a specific drug may be called a “definitive” or “quantitative” drug test. Clinicians may order these as a follow-up to a positive screening test, which is a “confirmation” test. Or they may order a definitive test to identify and quantify a specific drug and associated metabolites — chemicals that form when the body breaks down a specific drug ­— without prior presumptive testing.
• Therapeutic: When a clinician orders a test to monitor patient response to a known, prescribed medication, that’s considered a therapeutic drug test. The provider may want to evaluate a change in the patient’s clinical state or treatment response, or consider blood concentration related to dosage, drug interactions, or possible toxicity.

Be aware that a therapeutic drug assay is only for medication prescribed to the patient. If a provider orders a test suspecting that a patient is abusing a drug without a prescription, you should report the test as a definitive drug test.

Procedure: Identify the Lab Method and Reporting

Each drug test purpose leads to a different set of procedure codes from which you can select the proper way to report your lab’s work. The lab may perform a drug test on specimens such as urine, saliva, or blood.

For screening tests, you’ll select one of the following codes based on the specific technique or tool used, such as direct optical observation with or without instrumentation, or a chemistry analyzer instrument:

• 80305 (Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service)
• 80306 (... read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service)
• 80307 (… 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)

Notice: You may report only one of these codes one time on a given date of service no matter how many drugs or drug classes are in the evaluation. Also, you may not separately report sample validation — the steps performed to ensure that the specimen is the identified fluid from the specific patient.

Definitive: If the lab performs a more specific procedure to determine the level of a particular analyte in the specimen, you’ll often turn to one of the codes in the 80320 (Alcohols) to 80377 (Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more) range. The appropriate code for the test will depend on the analyte, which CPT^® organizes alphabetically by analyte name.

The lab procedure for these codes allows identification of individual drugs and structural isomers using methods such as chromatography and mass spectrometry, but not immunoassays or enzymatic methods that you might see in the screening tests.

Therapeutic: When the lab tests for a known, prescribed, or over-the-counter medication, you’ll turn to codes in the 80143 (Acetaminophen) to 80299 (Quantitation of therapeutic drug, not elsewhere specified) range. These codes are also quantitative and include any measured metabolites. CPT^® also organizes these codes alphabetically by analyte name.

Payer: Know the Beneficiary’s Insurance

If your lab performs a drug test for a patient using Medicare or Medicaid, you may need to turn to different codes for certain procedures.

Medicare does not accept the CPT^® definitive drug test codes 80320-80377. Instead, you’ll need to turn to the following codes for Medicare beneficiaries:

• G0480 (Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers)… (2) stable isotope or other universally recognized internal standards in all samples…, and (3) method or drug-specific calibration and matrix-matched quality control material… qualitative or quantitative, all sources, includes specimen validity testing, 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)
• G0483 (... 22 or more drug class(es), including metabolite(s) if performed)
• G0659 (Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers)…, excluding immunoassays… performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes)

Note: You must use G0659 instead of a code from the G0480-G0483 range if the procedure your lab performs does not meet the calibration, quality control, or internal standards described in the G0480 family.

Medicaid: Many state Medicaid agencies require H0003 (Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs) to identify mental health services related to alcohol- and drug-abuse treatment.

Proof: Show Medical Necessity

Identifying the correct procedure code won’t help you get paid if you don’t properly demonstrate the diagnosis that justifies the test. The ordering clinician will identify the medical necessity for the test with a narrative diagnosis or by assigning an appropriate ICD-10-CM code.

The following list can give you a glimpse of the types of diagnoses you might see with a drug test order:

• Drug abuse codes such as F10.- (Alcohol related disorders), F11.- (Opioid related disorders) through F19.- (Other psychoactive substance related disorders)
• R40.- (Somnolence, stupor and coma)
• T14.91 (Suicide attempt)
• Poisoning codes such as T39.- (Poisoning by, adverse effect of and underdosing of nonopioid analgesics, antipyretics and antirheumatics) through T50.- (Poisoning by, adverse effect of and underdosing of diuretics and other and unspecified drugs, medicaments and biological substances)
• Z51.81 (Encounter for therapeutic drug level monitoring)

Tip: Don’t forget to abide by any instructional notes if you use one of these codes. For example, ICD-10-CM instruction for Z51.81 states that you must “Code also any long-term (current) drug therapy (Z79.-).”

Ellen Garver, BS, BA, Contributing Writer