Wiki 80101 vs G0431 - I work with several pain management

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brockorama01

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I work with several pain management practices who drug screen/test. I just attended a dinner meeting/sales pitch with a rep from a "table top drug screen reader" company.


His pitch is this:
With the new G0431 code, Medicare will no longer pay for the single class test without performing the screen on a table top reader. The table top reader costs $80,000 to buy or $2,000 to lease. With our volume of 40 - 60 screens per week and reimbursement of $20 per class, the numbers still work.

Here are my questions:
1. The verbage is the same for both codes, what's the difference?
G0431 - DRUG SCREEN, QUALITATIVE; SINGLE DRUG CLASS METHOD (E.G., IMMUNOASSAY, ENZYME ASSAY), EACH DRUG CLASS

80101 - Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class

2. When does new code take effect? NGS Medicare has an LCD (28145) with BOTH codes on it. It does not indicate when G0431 becomes effective for Part B. (It states that Part A carriers will be effective April 1st)

3. Does the new code require a table top reader and not just urine dip strips?

4. Finally, NGS Medicare IIndiana) does not list either code G0430 or G0431 on their fee schedule yet. Does anyone know reimbursement rates?

Brock Berta, CPC
Billing Czar
 
For G0431:

Per Flashcode.com

"This active HCPCS code became effective on: 01/01/2010

Medicare coverage status is listed as 'C' = Carrier judgement.

There are no Cross Reference Codes listed for this code

Pricing for this code is determined by the Physician Fee Schedule with the price established by carriers (e.g., not otherwise classified, individual determination, carrier discretion

There are no HCPCS Coverage Issues Manual references for this code

There are no Medicare Carrier Manual references for this code

There is no HCPCS Statute Reference number for this code. "

I don't see why you couldn't bill this for just the strips. I would use the above information as a jumping off point and try to contact CMS for clarification. Sometimes, salesmen will tell you whatever they need to......
 
According to MLN Matters Number SE1001, "From January 1, 2030 through March 31, 2010, when performing a qualitative drug screening test for a single class of drugs, regardless of the testing methodology, those clinical laboratories that do not require a CLIA certificate of waiver should bill new test code G0431. Those clinical laboratories that do require a CLIA certificate of waiver should continue to utilize CPT Code 80101QW".
 
This is what we got from a reference company we use.

What You Need to Know
Drug Screening Codes

Following are the current definitions of all test codes addressed in MLN Matters SE101:

CPT® Code 80100 – Drug screen, qualitative; multiple drug classes chromatographic method, each procedure

G0430 – Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure

CPT® Code 80101 – Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class

CPT® Code 80101QW – Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class

G0431 – Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class

Multiple Drug Class Methods

MLN Matters SE101 provides the following billing instructions for the period of January 1, 2010 through March 31, 2010:

Chromatographic Method: When performing a qualitative drug screening test for multiple drug classes using chromatographic methods, CPT® Code 80100 is the appropriate code to bill.

Other Methods: When performing a qualitative drug screening test for multiple drug classes that does not use chromatographic methods, new test code G0430 is the appropriate code to bill.

Single Drug Class Methods

MLN Matters SE101 provides the following billing instructions for the period of January 1, 2010 through March 31, 2010:

Laboratories Holding Moderate or High Complexity CLIA Certificates: When performing a qualitative drug screening test for a single class of drugs, regardless of the testing methodology, those clinical laboratories that do not require a CLIA certificate of waiver should bill new test code G0431.

Laboratories Holding CLIA Waiver Certificates (labs that perform only waived tests): Those clinical laboratories that do require a CLIA certificate of waiver should continue to utilize CPT® Code 80101QW.
Action Needed
Be sure laboratory and billing staff are aware of these billing instructions.
Effective Date
01 January 2010
Background
N/A
Reference
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE1001.pdf

What You Need to Know
Effective January 1, 2010, two new G-codes (G0430 and G0431) were added by CMS to keep pace with the newer drug screen technologies. The new G codes distinguish between a multi-drug immunoassay method (G0430) and an immunoassay method covering single drug classes (G0431). In the 2010 OPPS Final Rule, published in the November 20, 2009 Federal Register, the CPT® drug screen codes 80100 and 80101 were listed with status indicator “E”. Recently, CMS released an updated Addendum B in which these codes were listed with status indicator “A”. When this change occurred there was widespread confusion among physician office and hospital labs concerning the appropriate use of codes 80100, 80101, G0430 and G0431 for drug screen testing. Craneware contacted CMS and received the following verbal guidance. According to the spokesperson at CMS, the agency will release further written authoritative guidance about how to bill for these tests in a future Medlearn Matters article. The following is a summary of verbal guidance provided by the CMS spokesperson:
• 80100 - Drug screen, qualitative; multiple drug classes chromatographic method, each procedure.
• 80101 - Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class.
• G0430 – Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure.
• G0431 – Drug screen, qualitative; single drug class method (e.g. immunoassay, enzyme assay), each drug class.
CMS stated that:
• CPT® 80100 will remain in effect in 2010 and G0430 will not replace it as this new G code has a different description.
o CPT® 80100 will continue to be used for the chromatographic method used to detect multiple drug classes simultaneously.
• CPT® 80101 is directly replaced with G0431, therefore CPT® 80101 will be changed back to “non-covered” as of April 1, 2010.
• G0430QW and G0431QW will be created for the CLIA waived laboratories.
• As of April 1, 2010 the following will be the only active codes:
o 80100
o G0430 and G0430QW
o G0431 and G0431QW
The CMS representative did not specifically comment on the use of the old codes 80101 and 80101QW between now and April 1, 2010. It appears these codes will continue to exist thourgh March 31, 2010. Facilities may use the G0431 now to alleviate conversion issues in April.
Action Needed
The laboratory and chargemaster staff should review the above CMS verbal instructions and pay close attention to the forthcoming Medlearn Matters article. Once a decision is made as to the facility’s preference for coding between January 1 and March 31 for CPT® 80101 versus G0431, then the chargemaster should be updated accordingly. We caution readers that this information is based on verbal communication with CMS and does not have the weight of authority. Providers should reaffirm this information with future written documentation from CMS and/or Medlearn Matters.
Effective Date
01 January 2010
Background
2010 OPPS Final Rule - Appendix B 2010 Laboratory Fee Schedule Final Payment Determinations
Reference
http://www.cms.hhs.gov/ClinicalLabFeeSched/Downloads/Calendar_Year_2010_rationale.pdf

see if any of this helps.
 
Nice work guys, thanks.

There are still some holes to fill in but this was very helpful.

G0430 is an new code to complement 80100.
G0431 replaces 80101 effective 4-1-10
Can avoid the rush and bill both now.
Widespread confusion.

If I am reading this correctly...the last big hole to fill in is whether our urine sample container/strip tests are chromatography or immunoassay. If test strips attached to sample container are immunoassay, then we do NOT need table top reader.

If the strips are not immunoassay, then the physician groups I work with will need to get a CLIA Moderate Complexity certificate and go table top.

Make sense?
 
Hi,

I have a pain physician who has a CLIA waiver and tests for several drug classes with a urine dip test, we have been billing 80101QW times the number of classes. He recently asked me to research the new code and has learned from one of his sources that CMS will not reimburse as much for the G0431. I could not locate pricing for this code on the CMS fee schedule. Does anyone know if this info is accurate?
 
I couldn't locate an exact fee either...and I checked Medicare in five states. From what I have heard for drug lab reps, the reimbursement will still be around $20 per drug class....only slightly less than the 80101.
 
If anyone is still listening...I have found the fee schedule for the new codes
G0430 and G0431.

Straight from the February Medicare Review from NGS Medicare, I found this on page 38:


HCPCS Code G0430 is priced at the same rate as code 80100.

HCPCS Code G0431 is priced at the same rate as code 80101.

There you have it.
 
G0431

Our MAC, Noridian, is applying the 20% coinsurance patient responsibility on the G0431 service. This doesn't seem right to me. Any thoughts?
 
I have questions specifically about using CPT code G0431 in 2010. I was directed to the NCCI office by our local carrier (WPS) and they have sent me information stating that offices who were testing using strips should not have been billing G0431 because that code in 2010 described high complexity testing and cups or strips are moderate complexity.

My questions:

1. If each strip tests for a particular drug class and we were performing up to 13 classes or "dips" on each urine sample in 2010....how can this be billed using a CPT code whose descriptor states "multiple drug class methods?" G0430 states "mulitple drug classes" but our NCCI contact states this should be used for moderate (cup & strip) coding in 2010.

2. The salesman provided us with information that stated the description of "each procedure" meant for each dip...who would expect any less from a salesman?? However, the contact person has indicated that it should be billed only once per specimen, regardless of the # of dips.

I would appreciate any clarification that you may have on these two issues. It's really too bad that Medicare is so vague and un-responsive sometimes!! Keep it a secret...but expect it to be done correctly at the same time.
 
For 2010:
G0430 – Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure
G0431 – Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class
Technically if an office was using a multi-class strip/cup then G0430 was to be used and billed once @ 1 unit. If they were using individual strips the G0431 was being used times however many classes (units) were tested at the point of care. This was also used if an analyzer was utilized.
Due to this overutilization of the G0431, at times inaccurately, CMS restructured the codes for UDS for 2011.
Most people believe the G0431 was originally meant for the high complexity testing when it was introduced in 2010, however because of the vague verbage it didn't clearly read that way.
CMS definitely made sure there was no doubt in anyones mind come 2011 that G0431 was, and is, for high complexity only now as of 1/1/11.
 
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