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New/Revised HCPSC Level II Go431 & G0434

  1. #1
    Default New/Revised HCPSC Level II Go431 & G0434
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    Good Afternoon. We are having some discussion about the changes in the drug screen codes for Medicare. The code G0430 has been deleted and is now cross referencing to G0434. The code G0431 has been revised and I am under the inderstanding that this code can only be billed in a laboratory setting and the code G0434 is the one to use in the office setting with the simple complexity(drug test kits0 or moderate complexity (analyser performed in the office. CLIA waived Is this correct? Thanks as always for the help.

  2. #2
    Default
    I was waiting for an MLN Matters article or listening to the up and coming 2011 pain webinars before I feel I will know anymore about this subject. I agree that these codes still seem like they might not be ripe enough to bill without some further clarification.

  3. #3
    Default G0434, 80104
    Hi there,

    While we've been able to find info (albeit only in a January MLN Matters) that G0430 has been deleted as of January 1, 2011, and that "G0431 is priced at five times the rate of HCPCS code G0430", the MLN Matters doesn't even mention G0434 except to say that "G0434 is priced at the same rate as code G0430" (p 14, Jan. 2011 NHIC "J 14 A/B MAC Resource").

    The only info we've been able to find that says G0434 is what we should be using when we had been using G0430 is on forums (like this), and no one seems to point to anything more concrete. Not that I don't trust all of our experience, but we've got to have some harder guidance. Does anyone have a medicare or CMS contractor publication etc. that they can recommend that offers guidance on G0434?

    And are folks who have been using 80101 x ___ now using 80104 x 1? And if so, did you use the resource outside of CPT for that guidance?

    Thanks for the help - we're hitting our heads against the wall over here!

    spstarke, CPC

  4. #4
    Default
    Spsparke,

    What is you office's scenario?

    Are using for example, 11 panel CLIA drug test kit. Having the nurse adminster the test. Using a drug test worksheet to mark the postive and negatives. Then bill G0434 for Medicare/Medicare replacements (Evercare, Care improvement plus, Secure Horizaon, Humana Gold Plus, Coventry Advantra, etc..) or 80104 for commercial or non medicare payers.

    Have you ran into the predictment that QW is not on the clinicla lab fee schedule next to
    G0434. And getting denials that QW is a invalid modifier with G0434. I would assume that the did not put the a line for G0434 QW by error. Whereas they created G0431 and G0431 QW which would be less likely that the office would be doing high complexity testing.

    Are you do the drug test panel then sending the specimen within the drug test kit to a lab to run the specimen and provide an official report and a more reliable test method than the drug test kit. Has the lab relayed how their test method measures on the complexity scale. Are their prices past on what drug test would be reimburse in 09' or 10' and is not consider feasible with the new codes/new reimbursement.

    These are some things that come to mind. Without knowing the exact process or sceanario in which you office does the drug testing, mainly is each specimen going to the lab. It is hard to know which things to point out to consider. To me, if you are only do a drug test kit in the office that is not be sent to a lab then the current reimbursement for
    G0434 would cover the cost of doing this and I don't know much more you could do to change to report it better. If you are doing only a drug test kit in the office not sending it to the lab, the CPT manual seems to be pretty straightforward that 80104 is the code to report. And I assume the carriers reimbursement for 80104 would cover the cost of the test. For me, alot of the questions start coming when sending it to the lab to confirm results and the costs from the lab. And covering those costs with G0434 or 80104.

  5. #5
    Default
    dwaldman - thanks for the feedback.

    Our scenario is much like your example - though I assume that if folks are getting denials for the QW on G0434, it is because G0434 specifies CLIA waived as part of its descriptor, and so it would be redundant with the QW modifier...
    And we're coding a CLIA waived, multi-panel cup, plus a single dip outside the cup. And only sending specimens as needed for confirmatory testing, so not every time. Are you saying in those instances, you'd use 80102? I was under the impression that if our client sends a specimen for confirmatory testing, that we should not code the G0434 (or the 80104) - similar to billing an 81002 when the client has sent the specimen to a lab for full urinalysis.

    Thanks for your help thus far, any outside references you can refer me to would be great.

    Thanks!
    spstarke

  6. #6
    Default
    In the past /back in 2010, we were billing for non-medicare carriers 80101 x 11. An 11 panel drug test kit was used. After the results of the drug test kit were reviewed by the ordering phyisician. The drug test kit was sent to the lab. They would run the test to verify that it was urine, that it was not altered, and they would use the most complex method. The doctor would wait for these results from the lab and would go over these results with the patient the next visit. The doctors feel the lab results are more reliable so every specimen is sent to the lab. We would still bill 80101 x 11 as the only code which would cover the cost of the cup and the cost of the lab to provide a report and the more reliable read. In April 2010, the lab had to provide all drug tests for Medicare and Medicare replacements due to the fact that G0430 reimbursement would cover the cost for what the lab charged to read it and there would be a potential over 50 dollar loss for the facility per test. Going forward for 2011, there is still a lot to find out. We have not bill any tests for 2011 and are working to get a better understanding. We listened to a UDS webinar on Audioeducator in 2010 and plan to look for one in 2011. Also looking for MLN Matters or transmittals from CMS or a full description of serivce piece that would be beneficial for the AMA to put out in an outcoming CPT Assistant for 80104 with dos and donts.

  7. #7
    Default
    I meant the lab would use a "more complex method" than the drug test kit.

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