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Thread: Help w/G0431 Louisiana

  1. #1

    Default Help w/G0431 Louisiana

    AAPC: Back to School
    We're a pain practice in New Orleans and we are getting denials on G0431. Any help from a practice in LA on how many units you are being paid and how you are billing would be great. Thanks.

  2. #2
    Join Date
    Apr 2007


    Have you seen the new 2011 CPT book with new CPT code for drug testing

    80104 Mulitple drug classes other than chromographic; each procedure

    What CPT has done has adopted Medicare's concept by duplicating the descriptor from


    G0430 is the code you should be using if you are doing multiple drug classes using a drug test kit with quantity one. G0431 is if you are only testing a single drug class such as opiotes. The reimbursement issue of paying 100 plus per drug test with code 80101 and paying 20 dollars per class was the reason the G0430 was created and the same reason 80104 is going to be the code in 2011 so Medicaid programs and other non Medicare carriers are not paying out such high reimbursement for urine collection and testing. What you have to do is find out how much it costs for the cup you are using. Then how much the lab is charging your group or facility to read, confirm postives, and fax a report. What you might find is the lab might not be able to get their fee low enough so you don't losing money and you would have to switch over to a company or lab that does it own billing.

  3. #3
    Join Date
    Apr 2007


    Now that I found out more information about the 2011 drug screening codes for Medicare I wanted to post another response to your question. They are going to have two codes-one code is G0431 as a revised code for high-complexity testing that is done at a lab which would reimburse at around 104.00 for the cost of this type of testing to be performed for multiple drug classes performed in a Lab setting. Then there would be code GXXX1 which would be for CLIA-Waived point of care testing (simple) or(moderate) testing reader outside laboratory setting that some might have in their office. The new G code for point of care testing that is not being sent to the lab I would assume would have the twenty or less reimbursement. It makes sense that they would have two codes each where it covers as many drug classes as you are testing and reimbursement is based on the complexity or the cost of the resources used. Hopefully I understand it correctly.

  4. #4
    Join Date
    Apr 2007
    Denver Colorado


    Anecdotal reports have noted that Medicare has implemented a non-published MUE limit of 4 units of service for G0431, that may be the reason for the denials.

  5. #5


    CMS published documentation on G0431. They are changing the description from per drug class to per patient encounter. They are pricing at 5x their 2010 rate for 2011; which is interesting given the unpublished MUE of 4.

  6. #6

    Default G0431

    if you read the fine print, the G0431 is for high complex labs only. the way i read this is that practices will only be able to be for G0430 or whatever the new code is. i don't think they determined the reimbursement for G0430 yet. it's $20.83 now. we'll see......

  7. #7
    Join Date
    Apr 2007


    G0430 will be deleted. G0434 will take it place.

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