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CPT codes 80101 versus 80104

  1. #11
    Medical Coding Books
    What is a High Complexity test according to CMS?
    According to CMS code G0431 now applies to a high complexity test only. This test
    (with its higher reimbursement rate of $120.33) is specific to its FDA approved
    complexity in its 510(k) application. A high complexity lab must perform this test.
    The personnel required in this lab must meet the specified CLIA Clinical Laboratory
    Personnel Requirements. The details of these requirements can be found at:

  2. Default 80104
    When billing 80104 multiple drug classes, do you bill just 80104 for testing for more than one drug or do you have to bill 80104 x # of drugs testing. Ex: testing for 3 different drugs do you bill 80104 x 3??? Can some one please help....

  3. #13
    we are still billing the 80101/QW for the commercial carriers and within just the last several weeks UHC has begun to deny this code outright. The other payers are still paying it. We did bill with the 80104 once and the reimbursement was about $25.00...I can't remember who the payer was. This leads me to another question. If Medicare is secondary, do you change the code from 80101 to the G code and them bill MC since MC doesn't recognize the 80101 code anymore? We have this situation in our office fairly regularly and have't been able to really find anyone who seems to know for sure what to do.

  4. #14
    It would nice to be able to know if the CPT manual for 2012 will adapt this breakout of drug testing by complexity.

    In regards to drug testing, at the beginning of 2010, WPS Medicare J5 is reprocessing claims based on adjusted fee schedule. Since back in 2010, the hospital was not able to use G0430-QW until April 2010----between January and April 80101 was being used Now they are reprocessing these claims they are saying that 80101 is invalid and denying and was pointing to a transmital or MLN Matters article saying that although you could not bill G0430-QW until April that it is retroactive to January 2010. This is kind the latest thing we have been dealing with in regards to drug testing.

  5. #15
    I have a PCP that is turning in 80101 x 12 on every patient. He states that he tests for "every drug class on every patient doing a UTS". Not that I doubt him, but I am a little leary of billing 80101 x 12 for every patient. I don't have access to the patient charts (outside biller), but the CMA states that they document in every chart that they are doing a "12 drug class UTS" and this is documented in every patient chart. Thoughts?

  6. #16
    AMA CPT Changes 2011

    Code 80104 has been established to report a specific drug screen, qualitative analysis by multiplexed method for 2-15 drugs or drug classes (eg, multidrug screening kit). The existence of CPT codes and HCPCS Level II codes reportable in 2010 for drug testing created confusion regarding appropriate reporting of qualitative drug screen testing and imposed additional administrative burdens on providers. Code 80104 has been established to report qualitative analysis drug screen by multiplexed method. A cross-reference has been added following code 80101 to direct the user to 80104. Code 80104 appears with a number symbol () to indicate that this code appears out of numerical sequence...

    __________________________________________________ ________________________

    If urine drug test kit is being used, the reporting would 80104. The provider might of been educated on the code change in 2011 for drug test kit that simulatenously tests for mulitple drug classes in a single procedure.

  7. Default
    dmaines40505...I see your point on what you are asking. If you are doing urine test strips and you have to individually dip each drug class it seems that should fall under cpt code 80101 and billed per class. but if you are dipping all drugs as once then it should fall under 80104. It is so confusing at times!

  8. Default
    So what is the clear answer..... If a physicians office is using a high complexity machine and are running 9 different classes of drugs for commerical carriers what is the best code?

  9. #19
    The physician would have to CLIA certification to perfom high complexity tests and incur the costs to have the required personel to have in office lab and the instrument/supplies in order to perform high complexity tests. The confirmation testing can require methods such as: Gas chromatography–mass spectrometry (GC-MS

    The above link is the FDA's CLIA test complexity database and an instrument name/manufacturer/model can be searched and determined if for example the instrument is able to perform what would be considered as moderate or high complexity test

    In certain situations, an location could have an in office analyser which can fall under moderate complexity and Medicare has stated that currently G0434 would have to report for the tests results/confirmation that these type of instruments can provide. Which in the past was requested an additional G code to describe this type of testing and not placing under the same category as drug test kit but change request was not granted for a new code.

    In regards to 80101 versus 80104, AMA CPT Assistant stated described the 80101 use:

    "Methods then became available that relied upon immunoassay or enyzme assay in which an assay identfied the presense or absence of drugs within a single class. Each test run was for just one class and code 80101 Drug screen, qualtative; single drug class method (eg immunoassay, enzyme assay), each drug class."

    It would seem in a lab setting or location that a high complexity/certification, these instruments that are performing a high complexity test would best be describe by using 80101 per class.

    I have not seen guidance from the AMA regarding in office analzyer that by CLIA standards would be considered moderate complexity and the reporting of this with the current CPT codes available that don't describe the complexity in their descriptors. It does seem they focus on drug test kits for 80104 and don't describe other methods they consider for 80104.

  10. Default
    Thanks for the information, it is very helpful.
    That is what I concluded to, but just wanted to make sure I was on the same page as someone else. It would be really simple if they would word things a little differently. I appreciate your quickness with a response.

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