Definitive Drug Testing for Cigna

Walker22

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Cigna has recently released a drug testing policy that allows 8 definitive tests per date of service. Due to this limitation, they have determined that G0482 and G0483 are not medically necessary (because both codes exceed the 8 test maximum) and not payable. My lab now has a coding dilemma:

1. Physician orders 19 definitive tests for a Cigna patient.
2. My out-of-network lab performs the tests as ordered.
3. The code for this service is G0482, which Cigna says it is not medically necessary.
4. Can the lab bill G0481 to at least cover some of the tests?

Thoughts?
 

Walker22

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Hmm... I'm surprised that no one has commented on this!

For the record, I know the answer is that it can't be done. Downcoding is just as bad as upcoding. I was asking for my boss, who wanted to get a consensus. I tried asking the question in a way that didn't give away my own thoughts on the issue. Anyway, I have found other documentation that supports my position. Still surprised that no one spoke up!
 

CodingKing

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My only questions is why a physician is ordering 19 definitive tests. Why not just run presumptive and go from there based on the results?
 

Walker22

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My only questions is why a physician is ordering 19 definitive tests. Why not just run presumptive and go from there based on the results?
I understand your point of view, but I only work for the lab's billing service, not the ordering physician. I will say that there are many tests that are not testable by presumptive screening. In a pain management setting, there is no room for error by the physician. If he doesn't test for something, and there is a bad reaction or an overdose to something he prescribed, then the physician is liable for a malpractice suit. On top of that, the cutoff's used in presumptive testing do not work well for every patient. All in all, doctors do not trust presumptive screening when it comes to their livelihood. They want definitive tests when high risk drugs are involved.

Caveat: I obviously do not speak for all doctors. I am only relating the views expressed by the doctors I have worked with in the pain management environment, which I have been involved in for the last 10 years.
 

CodingKing

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Thanks for the input. Its been a trend I've been watching the last decade with excessive not medically necessary drug testing, Its one of the reason Medicare has been dragging its feet assigning rates to the 80000 codes and why companies like CIGNA capping the number. Especially seeing some labs running definitive tests on nearly all drug of abuse classes multiple times a week even for patients who consistently test negative.
 

Walker22

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Thanks for the input. Its been a trend I've been watching the last decade with excessive not medically necessary drug testing, Its one of the reason Medicare has been dragging its feet assigning rates to the 80000 codes and why companies like CIGNA capping the number. Especially seeing some labs running definitive tests on nearly all drug of abuse classes multiple times a week even for patients who consistently test negative.
I totally agree that running bulk definitive tests multiple times a week on the same patient, even if they test positive, is overkill. The physicians that I have worked with only run the tests once or month or less, depending on the individual patient. Limiting them to 128 tests a year like Cigna has done limits their ability to determine whether a prescription for a high risk medication is appropriate or not, and this creates a malpractice risk for the provider. At worst, it will create a chilling effect on high risk prescriptions for people that really need them, which would be a shame.
 

suemt

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Hmm... I'm surprised that no one has commented on this!

For the record, I know the answer is that it can't be done. Downcoding is just as bad as upcoding. I was asking for my boss, who wanted to get a consensus. I tried asking the question in a way that didn't give away my own thoughts on the issue. Anyway, I have found other documentation that supports my position. Still surprised that no one spoke up!
I don't get to these forums as often as I'd like to, but I would be tempted to try a couple different things with this. First off, this should be the exception rather than the norm so we shouldn't be talking about a lot of cases in the big picture. There aren't many situations that call for that extensive testing, especially when you are talking about classes. I would be tempted to try a couple different things in a test mode to see what works:

Bill 2 lines using a Gx modifier on the second line to show you don't expect to get payment (maybe GZ?)
Plan to submit appeals for those G0482/G0483 services to document the medical necessity. That will enable the physician to describe the specific circumstances under which the full test should be paid. Honestly, unless there are just a few exceptions or these providers are treating a particularly challenging patient population, there shouldn't be a problem. Many of these edits are just what I call first line denials. If medical necessity can be supported, they will be paid.

Will be interested in seeing what you wound up doing.
 

Walker22

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I don't get to these forums as often as I'd like to, but I would be tempted to try a couple different things with this. First off, this should be the exception rather than the norm so we shouldn't be talking about a lot of cases in the big picture. There aren't many situations that call for that extensive testing, especially when you are talking about classes. I would be tempted to try a couple different things in a test mode to see what works:

Bill 2 lines using a Gx modifier on the second line to show you don't expect to get payment (maybe GZ?)
Plan to submit appeals for those G0482/G0483 services to document the medical necessity. That will enable the physician to describe the specific circumstances under which the full test should be paid. Honestly, unless there are just a few exceptions or these providers are treating a particularly challenging patient population, there shouldn't be a problem. Many of these edits are just what I call first line denials. If medical necessity can be supported, they will be paid.

Will be interested in seeing what you wound up doing.
What we wound up doing is billing the code that best describes the service we provided. We then get a denial based upon their medical policy. We then ask the doctor that ordered the tests to provide documentation to support medical necessity. We provide those documents to Cigna as an appeal. So far, all have been denied.
 

KariChairez

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Cigna has recently released a drug testing policy that allows 8 definitive tests per date of service. Due to this limitation, they have determined that G0482 and G0483 are not medically necessary (because both codes exceed the 8 test maximum) and not payable. My lab now has a coding dilemma:

1. Physician orders 19 definitive tests for a Cigna patient.
2. My out-of-network lab performs the tests as ordered.
3. The code for this service is G0482, which Cigna says it is not medically necessary.
4. Can the lab bill G0481 to at least cover some of the tests?

Thoughts?
Would it be considered down-coding if you had less than 8 come back inconsistent? I think they are denying as not medically necessary because they only deem it necessary to confirm if the screen comes up inconsistent. They probably aren't seeing 22 inconsistencies in the screen, therefor any appeals get denied. So then, wouldn't billing G0481 still be appropriate if less than 8 were inconsistent?
 
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downcoding G codes

We are an independent lab and are having this issue as well; Cigna will not cover higher than a G0481. Humana will not cover any higher than a G0480. What happens, Cigna downcodes anything higher when they reimburse. Humana pays, then recoups the money a month later. Although I know we are not supposed to downcode, what do we do when a payer has a specific policy in place? Since we are independent, we don't have medical records. Are we going to have compliance issues if we just bill G0481's to Cigna and G0480's to Humana when a higher code, G0482-G0483 is ordered ? We will still test and send the results of what the provider ordered.
 

n2horses

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Just went through this scenario with our lab's billing. We provided education and LCD information as a base guideline to our ordering providers, who are internally changing their drug screening processes to support medical necessity requirements in their own patient records. The rules these insurances are adopting by restricting the number of drug classes tested, is to move away from the trend of "blanket" ordering for every patient of the pain management practice, etc. ordered the same full panel repeatedly throughout treatment, regardless of whether the patient reported or didn't report use of additional substances or illicit.

Basically the rule is to force the provider to order less tests, and a more customized test to the patient's background and drug history. Particularly if they have more than one test in a calendar year. If the first test, is a "blanket" full panel for the threshold testing, and the results are all negative, the insurance expects that if the patient reports a negative use history at the next screen and trusts the patient based on history, symptoms, dx, etc, the provider should not order the SAME full panel, but rather a custom panel of drug classes that MAY reflect a positive result, or order presumptively, or no test at all. (Medicaid started this trend, followed by 3rd Party Medicare payors focusing on individual dx codes, and now the commercials are capping as well)

It is assigning more responsibility on the provider and the treatment protocol/program, and making medically necessity over a longer period of patient history, harder and harder to document. Your providers documentation would need to be airtight to explain why all 15+ drug classes need to be ordered each time for that particular patient. Its rare, in my experience, that a patient sample has a positive or inconsistent result for more than 5 drug classes show on a sample at one time... Makes you wonder how a patient would even function or be living considering some of the fatal consequences of mixing multiple drugs and illicit at one time.

Our providers are now ordering customized panels for long term patients that would fit into the G0480/481 description after the initial test, and we are not having any issues getting paid as an OON lab, as long as the DX codes support the medical necessity as well.
 
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