Under coding on Urine Drug screens acceptable?

hsmith67

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Suppose G0480 is the only code from G0480-G0483 approved for reimbursement/on the fee schedule for a payer that makes up a considerable part of your payer mix. Suppose the provider is going to prescribe opiates for chronic pain and manage this pain long term. Suppose a new patient comes in to get established and seeks long term pain management. The prescribing physician wants to perform a G0481, G0482, or G0483 to see what he/she is dealing with, but the payer only reimburses G0480. Alternatively, an established patient may seem to be veering off the path of compliance or cause suspicion and the prescribing physician wants to perform a G0481, G0482, or G0483 to investigate suspicions.
Is it acceptable to perform G0481-G0483 and bill G0480 to get paid for G0480 so the test is not a complete loss of revenue? Given that G0481-G0483 technically includes (and then some) what is covered in a G0480, is it still wrong to down code what was performed and bill G0480?

Opinions are fine, but if you have relevant articles to refer me to, Medicare guidelines that speak to this specifically, etc. that would be most helpful.

Hunter Smith, CPC
 

mitchellde

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No you may never under code or overcode. You must code what is documented as performed. You may never code just for reimbursement.
 
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Hi,

You'll need to report exactly what was ordered, but a couple of things to consider -

1. If this payer covers G0659, and the definitive tests you're performing meets that definition, that's the code you should report.

Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem), excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes
This code was created for physician labs that aren't complex enough to meet the requirements for G048x codes. In addition, some payers will not accept the G04xx codes performed in physician labs. For more background on the creation of G0659 go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/Archive-Test-Codes-and-Payment-Determinations-files-.zip
and review CY2017-Clinical-Laboratory-Fee-Schedule-Test-Codes-Preliminary-Determinations.pdf and CY2017-Clinical-Laboratory-Fee-Schedule-Test-Codes-Final-Determinations.pdf.

2. Some policies may state the provider would perform the definitive test when a medically necessary presumptive test came back with unexpected or unexplained positives. Here is Palmetto GBA's LCD for reference https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35724&ver=59
 
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