Urine Drug Screens and Pain Management

erinal

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Tulsa
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Prior to the 2017 code changes we were billing G0479 and G0480 w/ DX code Z79.899 for our urine drug screens for opioid pain management. We have not had any issues billing this way. Since the new screen code 80307 became effective we have been using it along w/ the G0480 confirmation test, still using Z79.899.

We are getting denials from UHC and BCBS for both codes (80307 & G0480) stating "Rendering provider is ineligible to perform this service" And " The procedure code is inconsistent with the provider type/specialty (taxonomy).

When I called BCBS I spoke with 2 different reps on two different occasions about two different patients but with the same denial. Both reps said that all they actually need is medical records. But they aren't able to tell my *why* they need records. One rep speculated that maybe BCBS has put a flag on those codes to deny until they receive records?? The first rep did pull up our information/taxonomy that is connected to our NPI and she said that they are showing that we are pain management. So now we are sending records on every single BCBS patient who has had a UDS because they are ALL denying for this reason. Every one of them.

I'm puzzled because both BCBS and UHC are denying for the exact same reason. Has anyone else encountered this? Any advice?
 

karamac

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Glendale, Arizona
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G0480 Denial

The first question I have is are you performing both presumptive and definitive testing in office? G0479 now deleted, and 80307 are for the presumptive screening method, and G0480 reflects the definitive testing of 1-7 drugs classes on definitive technology (LC-MS/MS, GC-MS/MS etc.)

If you are performing definitive testing, in office, as an ancillary service, I would reach out to your provider representative and ensure that those CPT codes are part of your providers contract. In many cases, they are not, and providers will receive payment for a time period and then once an unpublished edit is reached the claims will be denied. Just because the codes are not excluded from the contract does not mean that they are included. Primarily this occurs with the definitive testing codes, not the presumptive screening codes due to the necessity of a provider being able to presumptive screen a patient for non-adherence to the treatment plan.

They are asking for medical records to review the medical necessity of the testing, and to ensure that you are actually performing the testing that you are billing for. So they will want to see not only the progress notes, but also the result report, and requisition. Even in house laboratories should have a requisition when performing definitive testing.

Some payers also now have specific exclusions on providers performing definitive testing in office, and UHC in some states (Florida, Texas- Arizona and California coming in 2018) Beacon Labs to act as a benefit manager for toxicology testing. The payers will also be pulling your CLIA number as well to ensure that you have the correct CLIA certificate for the testing that is being billed.

This is a very short answer to a complicated problem, so please feel free to email me privately. All I do is lab all day, every day so please feel free to reach out.



Kara McVey, CPC, CPMA
ilexconsultingllc@gmail.com




Prior to the 2017 code changes we were billing G0479 and G0480 w/ DX code Z79.899 for our urine drug screens for opioid pain management. We have not had any issues billing this way. Since the new screen code 80307 became effective we have been using it along w/ the G0480 confirmation test, still using Z79.899.

We are getting denials from UHC and BCBS for both codes (80307 & G0480) stating "Rendering provider is ineligible to perform this service" And " The procedure code is inconsistent with the provider type/specialty (taxonomy).

When I called BCBS I spoke with 2 different reps on two different occasions about two different patients but with the same denial. Both reps said that all they actually need is medical records. But they aren't able to tell my *why* they need records. One rep speculated that maybe BCBS has put a flag on those codes to deny until they receive records?? The first rep did pull up our information/taxonomy that is connected to our NPI and she said that they are showing that we are pain management. So now we are sending records on every single BCBS patient who has had a UDS because they are ALL denying for this reason. Every one of them.

I'm puzzled because both BCBS and UHC are denying for the exact same reason. Has anyone else encountered this? Any advice?
 

erinal

Contributor
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24
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Tulsa
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Thank you, Kara!

We have our patient's provide a urine sample in a cup (it IS a CLIA waived cup however we do not bill for that) we take the sample downstairs to our lab (owned by our clinic) and they use a machine to screen the urine for the presumptive results and then it screens for the definitive results. We do have those records/reports and we are providing them to BCBS. We also have the lab requisitions but I didn't think to send that...

My administrator spoke with the director for BCBS OK last night and he told her that we needed to be using G0659 for our confirmation testing? The reason has to do with the type of lab that we are (Non-Reference). Any thoughts on that?

I really appreciate your help!
 

April.Kleck

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Broken Arrow, Oklahoma
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We are having the same issue, so you are not alone! We had something similar happen not last year but the year before and the solution had to do with their documentation of the type of machine we use. (I wish we would have known this before we had invested hours upon hours of obtaining medical records and faxing, then mailing, then uploading via ERM.. as BCBS had issues with finding the records once we sent them in..

We are currently waiting to hear from our provider rep to see if this year's issue may have the same solution.
 

n2horses

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I am currently having the same issue with denials for 80307 & G048X performed on the same day, and after some research and interpretation have found that it appears CMS no longer considers it eligible for payment and not medically necessary to do both a presumptive test and a definitive test on the same patient, same DOS just because your provider orders that for all patients, regardless of the presumptive results, or regardless of how your lab runs panels for drug classes.

From Novitas LCD:
"Definitive testing to confirm a negative presumptive UDT result, upon order of the clinician, is reasonable and necessary in the following circumstances: a) The results is inconsistent with a patient's self report, presentation, medical history, or current prescribed medication plan (should be present in the sample) b) following a review of clinical findings, the clinician suspects use of a substance that is inadequately detected or not detected by a presumptive UDT ; or c) to rule out an error as the cause of a negative presumptive UDT"

It also states that blanket orders by a clinician for all patients of a practice, are not necessary and appropriate. Some providers order a presumptive on every patient and also a definitive to just confirm the presumptive result, however that is not medically necessary unless one of the above occurs. Definitive testing in particular must be individualized based on the individual patient's history.

If your practice or client is ordering 80307 on every patient, in addition to G0481 regardless of result, Medicare and some other payers will deny for medical necessity and you will need to appeal with medical notes to support he ordering of the definitive test. If the presumptive test was negative, and a definitive test was done anyways, they will deny payment.


Just my two cents from my experience recently... please feel free to share input or experiences too. I would love to get paid for the work we are doing, so if I am missing something, someone please share.
 

April.Kleck

Contributor
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Broken Arrow, Oklahoma
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Can you tell me where exactly you located this in the LCD? We recently sent off an appeal to Aetna for a November 2016 date of service and didn't find anything with this wording in the CMS documentation.. Is this maybe a 2017 update?
 
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