CPT codes 80101 versus 80104

NESmith

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In our Pain Management office we do drug screening for different drugs. We are having a disagreement as to which CPT code should be used for this. We are a CLIA-waived facility. I am getting conflicting information as to which one to use. Help and Thanks
 

dwaldman

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What are method(s) of testing that encompasses a drug test where you are.

Drug test kit described recently in December 2010 CPT Assistant

----Per Cpt Assistant Dec 10, "multiplexed' because of the ability to qualitatively assay multiple drug simultaneously. It is effectively running multiple tests at once, in a single procedure, due to the test kit desing. Prior to 2011, the reproting was commonly reported as mutliple units of code 80101, as code 80101 was not specific to a single or multiple sequential procedures. In 2010, HCPCS code G0430 was created to describe a non chromatographic method wherein multiple drug classes were screened in a single procedure. New code 80104 more accuratley reflecting the resources used in a multiplex test kit as compared to multiple runs using a single class methodlogy.

80101 can it still be used in 2011?

They describe use of 80101 in the same article: "Methods then became available that relied upon immunoassay or enyzme assay in which an assay identfied the presense or absence of drugs within a single class. Each test run was for just one class and code 80101 Drug screen, qualtative; single drug class method (eg immunoassay, enzyme assay), each drug class.
 

NESmith

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Thank You so much as always for your response, but I now have another question. If the test is done in the office with a drug kit and then to the lab for further testing would you use the new CPt code 80104-GW with one unit or 80101 with mulitple units?
 

dwaldman

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You would need to contact the Lab and talk to for example the toxicology director or your representative assigned to you from the lab. Say that you need to know their test method----is it?----they are testing a single drug class using immunoassay or enzyme assay in a single run. So in essense if they are testing five drug classes, they are doing 5 procedures. Versus testing that is other than chromographic that simulatneously tests multiple drug classes. I think once you have in writting what type of testing they are doing then you confirm the appropriate code to bill. We also have the same scenario you are describing of doing the drug test kit as "initial field test" then sending the specimen within the kit to the lab so they can provide a report do their style of testing. We are in process of confirming what type of testing they are performing. Still a lot to review before we will be able to bill for any drug tests for 2011. Sending to the lab and doing our own billing makes a lot more in depth understanding that we are still looking to acquire.

It is interesting that you can go back eleven years a look at the CPT Assistant article for drug testing and things that I did not pay much attention to when it was just 80101 x classes. Now I am trying to better understand it when there are more codes, more involvement with AMA and CMS with modifications, and still more questions.
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2010 CPT Assistant March

For example, immunoassays, which are used to identify single drug classes, should be coded using 80101 (when used in drug screening), whether the test is performed using a random access analyzer, a single analyte test kit, or a multiple analyte test kit. Chromatography, which can identify multiple drug classes, is coded using 80100 (when used in drug screening).

For code 80100, each combination of stationary and mobile phase is to be counted as one procedure. For example, if screening for three drugs by chromato-graphy requires one stationary phase with three mobile phases, report 80100 three times. However, if multiple drugs can be detected using a single analysis (eg, one stationary phase with one mobile phase), report 80100 only once.

For code 80101, each single drug class method tested and reported is to be counted as one drug class. For example, if a sample is aliquoted to five wells and separate class-specific immunoassays are run on each of the five wells and reported separately, report 80101 five times. Similarly, if a sample is run on a rapid assay kit comprising five class-specific immunoassays in a single kit, and the five classes are reported separately, code 80101 should be reported five times.

80101, Drug, screen; single drug class, each drug class. A 30-year-old female, with a history of anxiety and depression treated with prescription medications, comes to the ED in a coma. The treating physician orders a drug screen for alcohol, barbiturates, benzodiazepines, phenothiazines, and tricyclic antidepressants. The laboratory performs single drug class screening for each analyte using immunoassay or enzyme assay methods in a random access analyzer.

To code this you would use 80101 times five, because this code is used to report immunoassay and enzyme assay, single drug class methods. Five units are reported as each single drug class is reported separately.

80101, Drug, screen; single drug class, each drug class. A 25-year-old male with a history of illegal drug use comes to the ED in a coma. The treating physician orders a drug screen for amphetamines, barbiturates, benzodiazepines, cocaine and metabolites, opiates, phencyclidine, and tetrahydrocannabinoids. The laboratory performs single drug class screening for each analyte using a multiple analyte rapid test immunoassay kit.

To code this you would use 80101 times seven, because immunoassay single drug class methods are reported using this code regardless of platform (random access analyzer or multiple analyte test kit). Seven units are reported as each single drug class is reported separately.
 

dwaldman

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At the bottom of my response I was trying to reference CPT Assistant March 2000. But accidently typed 2010.
 

NESmith

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You're the best and Thank You so much as always for your help. But, and you knew that was coming, I have yet another question. I spoke to our Medicare carrier and they said that at this time the CPT code 80104 is invalid and there is no fee schedule for this code. I have not checked with any of our commerical carriers, so my question is, should we check with our commerical carriers to see whether they are using the CPT code 80104 and what their fee schedule is or for the commerical carriers should we continue to use CPT code 80101Q? I know this is more of a billing question, but your answer would be greatly appreciated.
 

brockorama01

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Also a quick word about what the confirmation lab is billing versus your office:

As you know, there are the two types of tests for drug screens - qualitative and quantative. Qualitative (described by the 80101, 80104, G043...) are the quick yes/no tests. Pain specialists use these because they give a reasonably accurate result (70 - 85% accurate depending on who you ask), right there in the office when the physician has a script pad.

Quantitative screens can only be performed by a reference lab with a very expensive Gas chromatography-mass spectrometry (GC-MS) machine. The quantitative gives actual numbers to describe drug levels.

The problem: Some reference labs try to bill the qualitative AND the quantitative. They make some kind of argument that they "have to" in order know what tests to run...yada yada. It's wrong. I have used six labs over the years (Ameritox, Millenium, E-Labs, Forensic Diagnositics, Forensic Fluids, and Avee). Two have tried to bill the qualitative. I fired them both. Make sure that your standing orders clearly state that if your office is billing the qualitative, they are not. Keep in safe place for when (not if) Medicare audits the lab.

Side reference lab issue: Also don't believe the hype from labs that every qualitative needs to be confirmed by them. My clinics test every new patient and established patients 1 - 4 times a year based on a risk scale. If you have a patient's with a very low risk of abuse and diversion..and the qualitative screen comes back clean, you don't have to confirm them. We confirm 60% of all qualitative screens.
 

straitfan

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80104

great discussion. what practices are confused about at this time is that Medicare has allowed practices to bill for G0431 if they are a high complex laboratory (reimbursement around $100) and commercial insurance has not defined or created a code/reimbursement for a high complex lab. typically, as we all know, commercial payers follow suit with medicare on a majority of all codes. commercial payers are now rejecting 80101 and telling practices to bill 80104 instead with reimbursement at around $20.

by not defining a code for a high complex laboratory, commercial carriers have created a real gray area for billing for commercial qualitative drug screens.

has anyone spoken to the commercial carriers on plans to match the medicare code G0431for a high complex lab?
 

dwaldman

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What is a High Complexity test according to CMS?
According to CMS code G0431 now applies to a high complexity test only. This test
(with its higher reimbursement rate of $120.33) is specific to its FDA approved
complexity in its 510(k) application. A high complexity lab must perform this test.
The personnel required in this lab must meet the specified CLIA Clinical Laboratory
Personnel Requirements. The details of these requirements can be found at:
http://www.mass.gov/Eeohhs2/docs/dph/clinical_lab/clia_lab_qualifications.pdf

http://www.alfascientific.com/wp-content/uploads/2010/04/Reimbursement-FAQs-Jan.-2011.pdf
 

Boston09

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80104

When billing 80104 multiple drug classes, do you bill just 80104 for testing for more than one drug or do you have to bill 80104 x # of drugs testing. Ex: testing for 3 different drugs do you bill 80104 x 3??? Can some one please help....
 

ChristieH

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we are still billing the 80101/QW for the commercial carriers and within just the last several weeks UHC has begun to deny this code outright. The other payers are still paying it. We did bill with the 80104 once and the reimbursement was about $25.00...I can't remember who the payer was. This leads me to another question. If Medicare is secondary, do you change the code from 80101 to the G code and them bill MC since MC doesn't recognize the 80101 code anymore? We have this situation in our office fairly regularly and have't been able to really find anyone who seems to know for sure what to do.
 

dwaldman

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It would nice to be able to know if the CPT manual for 2012 will adapt this breakout of drug testing by complexity.

In regards to drug testing, at the beginning of 2010, WPS Medicare J5 is reprocessing claims based on adjusted fee schedule. Since back in 2010, the hospital was not able to use G0430-QW until April 2010----between January and April 80101 was being used Now they are reprocessing these claims they are saying that 80101 is invalid and denying and was pointing to a transmital or MLN Matters article saying that although you could not bill G0430-QW until April that it is retroactive to January 2010. This is kind the latest thing we have been dealing with in regards to drug testing.
 

dmaines40505

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I have a PCP that is turning in 80101 x 12 on every patient. He states that he tests for "every drug class on every patient doing a UTS". Not that I doubt him, but I am a little leary of billing 80101 x 12 for every patient. I don't have access to the patient charts (outside biller), but the CMA states that they document in every chart that they are doing a "12 drug class UTS" and this is documented in every patient chart. Thoughts?
 

dwaldman

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AMA CPT Changes 2011

Code 80104 has been established to report a specific drug screen, qualitative analysis by multiplexed method for 2-15 drugs or drug classes (eg, multidrug screening kit). The existence of CPT codes and HCPCS Level II codes reportable in 2010 for drug testing created confusion regarding appropriate reporting of qualitative drug screen testing and imposed additional administrative burdens on providers. Code 80104 has been established to report qualitative analysis drug screen by multiplexed method. A cross-reference has been added following code 80101 to direct the user to 80104. Code 80104 appears with a number symbol () to indicate that this code appears out of numerical sequence...

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If urine drug test kit is being used, the reporting would 80104. The provider might of been educated on the code change in 2011 for drug test kit that simulatenously tests for mulitple drug classes in a single procedure.
 

jenelite

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dmaines40505...I see your point on what you are asking. If you are doing urine test strips and you have to individually dip each drug class it seems that should fall under cpt code 80101 and billed per class. but if you are dipping all drugs as once then it should fall under 80104. It is so confusing at times!
 

jenelite

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So what is the clear answer..... If a physicians office is using a high complexity machine and are running 9 different classes of drugs for commerical carriers what is the best code?
 

dwaldman

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The physician would have to CLIA certification to perfom high complexity tests and incur the costs to have the required personel to have in office lab and the instrument/supplies in order to perform high complexity tests. The confirmation testing can require methods such as: Gas chromatography–mass spectrometry (GC-MS

http://en.wikipedia.org/wiki/Gas_chromatography-mass_spectrometry


http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/search.cfm

The above link is the FDA's CLIA test complexity database and an instrument name/manufacturer/model can be searched and determined if for example the instrument is able to perform what would be considered as moderate or high complexity test

In certain situations, an location could have an in office analyser which can fall under moderate complexity and Medicare has stated that currently G0434 would have to report for the tests results/confirmation that these type of instruments can provide. Which in the past was requested an additional G code to describe this type of testing and not placing under the same category as drug test kit but change request was not granted for a new code.

In regards to 80101 versus 80104, AMA CPT Assistant stated described the 80101 use:

"Methods then became available that relied upon immunoassay or enyzme assay in which an assay identfied the presense or absence of drugs within a single class. Each test run was for just one class and code 80101 Drug screen, qualtative; single drug class method (eg immunoassay, enzyme assay), each drug class."

It would seem in a lab setting or location that a high complexity/certification, these instruments that are performing a high complexity test would best be describe by using 80101 per class.

I have not seen guidance from the AMA regarding in office analzyer that by CLIA standards would be considered moderate complexity and the reporting of this with the current CPT codes available that don't describe the complexity in their descriptors. It does seem they focus on drug test kits for 80104 and don't describe other methods they consider for 80104.
 

jenelite

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Thanks for the information, it is very helpful.
That is what I concluded to, but just wanted to make sure I was on the same page as someone else. It would be really simple if they would word things a little differently. I appreciate your quickness with a response.
 

ricet911

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We have billed the 80104 * the number of units and were denied with a major commercial carrier saying it is bundled??? do these need modifiers or need to be on seperate lines?
 

dwaldman

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Would report 80104 with one unit. The code represents multiple drug classes being tested in a single procedure thru a drug test kit that tests the drugs simulaneously. It is not the same as the single class methodlogy of reporting as seen with 80101 which is performed on an instrument that is testing as a single run per drug class.
 

soprano

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Thank you for this discussion. We are using the CLIAwaived multiple drug cup test. It says it is an "immunochromatographic assay for rapid qualiative detection of drug combinations..." We were told to bill G0434QW x 1 to Medicare and 80101QW x 10 to all other carriers. I agree with the G0434 x 1 to Medicare, but think that 80104QW x 1 is a better code that describes this drug screen. This is a HUGE argument in our office. I am just looking for some confirmation.
 

dwaldman

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AMA CPT Changes 2011

Code 80104 has been established to report a specific drug screen, qualitative analysis by multiplexed method for 2-15 drugs or drug classes (eg, multidrug screening kit). The existence of CPT codes and HCPCS Level II codes reportable in 2010 for drug testing created confusion regarding appropriate reporting of qualitative drug screen testing and imposed additional administrative burdens on providers. Code 80104 has been established to report qualitative analysis drug screen by multiplexed method. A cross-reference has been added following code 80101 to direct the user to 80104. Code 80104 appears with a number symbol () to indicate that this code appears out of numerical sequence...

________________________________________________________________________
Above is from the AMA on reporting a UDS performed utiziling a drug screening kit. This would be an official source for coding guidance. You have look at what is realistic if you are billing Medicare with G0434 and receiving around 20.00 to cover the cost of the drug test kit. It would seem that if 80104 has a similiar reimbursement, 80104 would also represent the resources used. And per the AMA, 80104 was established for drug test thru a drug test kit.

80101 x 10 at 15 to 20 dollars a drug class would represent resources that are seen with a an instrument that can withstand repeat use, performs single runs per class, confirmation testing available for the specimen, and higher cost to perform the test across the board regarding qualified staff to perform the testing and manage quality of the testing, cost of the instrument/supplies, service contract and other costs to maintain the higher level of testing.
 
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