Wiki 80101 Humana Denying...HELP!!!!!!!

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mattrobin

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Hi,
i need some help, please! The pain dr's i work for, do random drug screens. I bill cpt: 80101-qw. However, humana medicare pffs; humana medicare ppo is denying that charge stating "considered part of the primary procedure". Usually we do bill an e&m w/ the drug screen, because the pt is being seen/ examed and the dr orders the drug screen before rx's can be written. Does anyone have any idea how to get humana to pay for this? Or do they just not cover??? Any help is appreciated.
 
We bill this to Humana alot, and have never had a problem. I would appeal and explain that X number of drugs are being tested for and that this is a covered procedure by Medicare (your specific MCR carrier). I would also give them how much Medicare's fee schedule is per drug being tested, probably about $19.00 or so each. Also explain this is in addition to the E/M and both are billable and payable. Are you checking your units on the claim for the 80101 QW and also bill the office visit without a modifier.
 
I have not seen Humana Gold denials for 80101...yet. Here is my two cents:

First off, Humana Gold is nuts: They deny all sorts of things they shouldn't like bilateral facet blocks, cervical disco's, spinal cord stim leads in an office setting...so this is not a surprise.

The denials for global - It could be the dx. Some carriers don't like pain dx's for the screens. Try the v58.69 for dx.

Some plans like Medicaid don't like paying for more than 8 or 10 units, but I've never heard of a Medicare plan.

The G code is not the answer. The G0431 replacement for 80101 doesn't take effect 'til 4-1-10...if then. Rumor has it that it will be delayed 'til summer.

Best advice: add modifier '25' to e/m, change dx on screen and argue, argue, argue.

Brock Berta, CPC
King of Drug Screens
 
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