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Which do I bill 80101 or G0431?

  1. #1
    Macon Local Chapter 2016 President Elect
    Default Which do I bill 80101 or G0431?
    Exam Training Packages
    80100 and 80101 vs G0430 and G0431

    I have several internal med practices that bill CPT 80100 and 80101 QW for point of care urine drug screen which are on the CLIA list. I understand that Medicare added new HCPCS code G0430 (for 80100) and G0431 (for 80101). The difference in the language is G0430 states "other than chromatographic method." Today I located a fee for all four codes are on the Cahaba B 2010 fee schedule. I also have other CMS articles stating that CMS intends to inactivate 80100 and 80101 as soon as G0430 and G0431 become active. Which code would the physician bill?

    Does that mean that the physician office lab should bill G0430 and G0431 in 2010? Or was G0430 and G0431 created for Clinical Labs? The tests are different. Several of the office are using QuickTox 12 and billing 80101 QW x12

    Judi Reid CPC

  2. #2
    St. Joseph County, Indiana
    Default 80801 vs G0431
    I have a few answers and more questions.

    I work with several pain management practices who drug screen/test. I just attended a dinner meeting/sales pitch with a rep from a "table top drug screen reader" company.

    His pitch is this:
    With the new G0431 code, Medicare will no longer pay for the single class test without performing the screen on a table top reader. The table top reader costs $80,000 to buy or $2,000 to lease. With our volume of 40 - 60 screens per week and reimbursement of $20 per class, the numbers still work.

    Here are my questions:
    1. The verbage is the same for both codes, what's the difference?

    80101 - Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class

    2. When does new code take effect? NGS Medicare has an LCD (28145) with BOTH codes on it. It does not indicate when G0431 becomes effective for Part B. (It states that Part A carriers will be effective April 1st)

    3. Does the new code require a table top reader and not just urine dip strips?

    4. Finally, NGS Medicare does not list either code G0430 or G0431 on their fee schedule.

    Brock Berta, CPC
    Billing Czar

  3. #3
    Default G0431 80101
    Providers may reference CR 6852, Transmittal 653, dated March 19, 2010

    For purposes of the Clinical Laboratory Fee Schedule (CLFS), beginning with dates of service on or after April 1, 2010, clinical laboratories should bill CPT code 80100 when performing a qualitative drug screening test for multiple drug classes that uses chromatographic methods.

    New test code G0430 was created to limit the billing to one time per procedure and to remove the limitation of the method (chromatographic) when this method is not being used in the performance of the test. Clinical laboratories performing a qualitative drug screening test for multiple drug classes that does not use chromatographic methods should:

    • Report new test code G0430 when a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver is not required.
    • Report new test code G0430QW when a CLIA certificate of waiver is required.

    New test code G0431 is a direct replacement for CPT code 80101. Effective April 1, 2010, CPT code 80101/80101QW will no longer be covered by Medicare. For purposes of the CLFS, effective with dates of service on or after April 1, 2010, clinical laboratories should:

    • Report new test code G0431 when a CLIA certificate of waiver is not required.
    • Report new test code G0431QW when a CLIA certificate of waiver is required.

    Effective: April 1, 2010
    Implementation: April 5, 2010

    The article, titled “Clinical Laboratory Fee Schedule (CLFS) – Special Instructions for Specific Test Codes (CPT Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW and G0431QW),” is available on the CMS MLN Matters® Web pag

  4. Default
    I also work in a pain management and was told that we are using the wrong DX. for the 80101 QW. We test are patients regularly so what DX. do you use? Has the code change for Medicare really went into effect? I know they kept changing the date.

  5. Default
    I use V58.83 and V58.69.

  6. Default
    Is there a limit to the number of units Medicare will allow on G0431?

  7. Default
    Our pain doc has started doing drug screens and we were told to use G0431-QW with the 2 dx codes mentioned above. When we submit this code to Medicare it is returned wih a billing error denial message. Should we remove the -QW modifier or use G0430?

  8. Default Medicare RDS
    We are Pain Management Practice and perform RDS as 11 drugs and total 9 drug classes.
    I am billing G0431-QW 9 units.

    Effective 07/01/2010 Medicare started denying claims with CO-151: Payment adjusted because the payer deems the information submitted does not support this many services. I spoke to Medicare (we are in Texas) and neither level one non two representative was able to provide reasonable explanations. The issue was sent to level three and it will take about 30 business days to get a response.

    I did not find any information (limitations) regarding number of units on MUE or on websites.

    I will appreciate any thoughts and comments regarding this issue

  9. #9
    Default units of G0431 and G0430
    Hi there,

    After MUCH exploration and discussion a few months ago (including reading the same above quote from the transmittal), we managed our way through the confusing language (like that G0431 is a direct replacement for 80101, which it's not...exactly). In an article by Attn. David Vaughn, "CMS Explains Drug Testing Codes G0430 and G0431", he suggests that G0430 x1 is to be used when testing multiple drug classes (when not using "chromatographic method"), i.e. in a multi-drug test screen cup. G0430 is limited to a unit of 1, for all drugs tested. He suggests that G0431 is to be used when performing a single drug class test.
    At our practice, we have an additional dip that is a separate class that we test for, and thus use G0430 QW x1 and G0431 QW x1 per appropriate patient/visit.

    Hope that helps.

  10. #10
    Effective 04/01/10 you should use CPT G0431 and one unit is maximum billable units for medicare.

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