Wiki New Drug Screen CCI Edits

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aquiel999

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I code for a multispecialty practice whose primary focus is on pain care. About 75% of our pain patients are on some form of controlled substance. DEA and our state medical board require us to perform urine drug screenings at regular intervals based on the patient's risk level. We have always billed 80307 for our presumptive that the lab runs which checks for alcohol and barbiturates and also the pH and creatinine as well as one of the following codes: G0480, G0481, G0482, or G0483 to test for a variety of specific drugs. Medicare on July 1 added a CCI edit that bundles the 80307 and the G code. At first, they were not allowing a modifier, but they have since retracted this and are now allowing them. How are you handling this new edit? Are you using a modifier? Would you use one in this scenario?
 
aquiel999 said:
I code for a multispecialty practice whose primary focus is on pain care. About 75% of our pain patients are on some form of controlled substance. DEA and our state medical board require us to perform urine drug screenings at regular intervals based on the patient's risk level. We have always billed 80307 for our presumptive that the lab runs which checks for alcohol and barbiturates and also the pH and creatinine as well as one of the following codes: G0480, G0481, G0482, or G0483 to test for a variety of specific drugs. Medicare on July 1 added a CCI edit that bundles the 80307 and the G code. At first, they were not allowing a modifier, but they have since retracted this and are now allowing them. How are you handling this new edit? Are you using a modifier? Would you use one in this scenario?
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Do you have a link or article in which it states that Medicare is now allowing a modifier? I have used teh 59 on a few Medicare Advanatge and Commercial Plans and have received payment, however, I have not tried it yet with Medicare. Thanks for your help!
 
sylviah said:
Do you have a link or article in which it states that Medicare is now allowing a modifier? I have used teh 59 on a few Medicare Advanatge and Commercial Plans and have received payment, however, I have not tried it yet with Medicare. Thanks for your help!
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Can you specify which commercial and MC Advant plans did pay?
 
cubuscrystal said:
Can you specify which commercial and MC Advant plans did pay?
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Not OP, but all we've seen for MCRADV & commercial are some BCBS/Elevance/Anthem payers either never updated to the new edits or have already updated to -59. Everything else is still denying. I'm the Medicaid/Managed Care guru where I'm at, but that's what I'm hearing from others.
 
Does this only apply to Medicare and any Medicare replacement plans? Are commercial plans following this as well?
My apologies if this has been asked, I am a newbie here.
 
amycolemanm said:
Does this only apply to Medicare and any Medicare replacement plans? Are commercial plans following this as well?
My apologies if this has been asked, I am a newbie here.
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Medicare, Medicare Advantage, Medicaid, and MCOs. It's up to the commercial plan as to if they want to follow NCCI edits; they're not required to. They usually do, though.
 
cubuscrystal said:
Have you received any payments from any payer with using modifier 59 on the G code?
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NO! no payments from any payer. I have appended a 59 first to the 8 code, no payment, I then appended 59 to the G code, no payment, have appended NO modifier 59 and still no payment. I have run this up the chain of command with our local MAC and we're still not getting any answers as to why none of this is working.
 
If anyone is still following this thread, I'd be more than interested in hearing what others are seeing with the presumptive and definitive testing.
 
Has anyone had straight Medicare claims go through your clearinghouse without being rejected by the payer? If so, which clearinghouse do you use? Has anyone else had any new or denied claims paid on by any other payer since the edit has been removed? We use WayStar in which our straight Medicare claims are still being rejected by the payer. The only payers that we are currently billing for that we have not received any rejects or denials from is UHC MA, TriCare, PF1 (delete the G code), and Aetna.
 
cubuscrystal said:
Has anyone had straight Medicare claims go through your clearinghouse without being rejected by the payer? If so, which clearinghouse do you use? Has anyone else had any new or denied claims paid on by any other payer since the edit has been removed? We use WayStar in which our straight Medicare claims are still being rejected by the payer. The only payers that we are currently billing for that we have not received any rejects or denials from is UHC MA, TriCare, PF1 (delete the G code), and Aetna.
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No, our MAC is Noridian, most of my claims are going through our CH without editing, some MAP payers that are still hitting edits (AARP/UHC a few others). On a positive note Noridian is paying current claims with urine drug screen codes and is re-processing past claims.
 
skiboi said:
We are receiving payments on current claims and Noridian is reprocessing past claims. :)
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Skiboi,

How are you all billing presumptive/definitive claims? Are you adding 59 modifier to the definitive on all claims? Or is it not necessary?
 
Our clearinghouse Availity is still showing rejected claims for UHC Medicare and their website shows the same for any claim that lists the 80307/G code. Has anyone else figured out a solution to this? The other payers are accepting the claims. I am in NC.
 
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My MAP are denying G codes when I bill with 80307 with or without the 59. I am going to try to apply the 59 to Gcodes. Medicare is paying both codes without the modifier
 
sarahthurston said:
Our clearinghouse Availity is still showing rejected claims for UHC Medicare and their website shows the same for any claim that lists the 80307/G code. Has anyone else figured out a solution to this? The other payers are accepting the claims. I am in NC.
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UHC has been dragging their feet. We have tons of claims sitting in a rejected status until they figure out what they're doing.
 
We used the UHC portal and added the denied claims under the research project tool since we had more than 20 denials. Waiting for them to be reprocessed. I'm in NC.
 
Has anyone been successful with getting UHC & UMR to pay on the UDT claims? Some of ours are being paid while others are being denied. UMR rep told us its bundled so we cant appeal, called back and spoke to a different UMR rep who is telling us we need a modifier and she didnt know anything about the CCI edit or medicare news.
 
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