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80101 confused! please help

  1. Default 80101 confused! please help
    Medical Coding Books
    We are just starting to bill Drug screening for our Pain Clinic. Im so confused, can someone explain when we bill 80101-QW and x how many or when we bill G0431? I have read different things on when to use each one and with or without modifier. I appreciate any feedback!

  2. Default
    usually you bill 80101 X 9 and then you add modifier 91 after the first one. hope this helps

  3. Default
    It depends on the payer as to which one you would use as far as I can see. Medicare and most of its MCO's are moving to the G0431 but some of the commercial companies are still staying with the 80101 I know that the lab i work at is billing with both and then we we get the denial we go ahead and fix it in our system so that it bills correctly. You may try to look at some fee schedules for the insurance that you are going to bill if you have time to do this before billing just to compile a list of who does and does not accept which codes and well as the number of units they will pay per code. I hope this helps.

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    As of 2010 Medicare requires the use of G0434 for low-moderate complexity (cups/strips) and G0431 for high complexity (analyzer), each can only be billed with 1 unit, regardless of how many classes are screened. The G0434 allows approx $20 and the G0431 approx $100, depending on the MAC/FI.
    QW modifier is used to indicate the test was CLIA waived.
    Some Medicaid and WC carriers have followed MDCRs lead and are requiring these HCPCS also, varies from state to state. These can be confirmed on the MDCD/WC websites through their fee schedules and/or medical policies.
    Commercial carriers as of right now are accepting the CPT codes of either ; 80101 (qualitative single class) or 80104 (qualitative multiple class, per procedure).
    Which are accepted and how they will allow you to bill, are individually determined.

    It is never a good idea to "hit or miss" claims. That sends red flags to carriers that best practices are not being followed. The idea is to get your claims out "clean" the first time. That will require research and due dillignece with each of your major carriers, maintaining up to date policies and staying on top of any upcoming changes. Initially, that all takes time to get it down pat, but the payoff in the long run is well worth it. Quick turn arounds from claim release date to payment, which equals low A/R, happy physicians/clinicians, and you as a valuable, well regarded, well compensated, employee....

  5. Default
    Can we use code 80101 for drug confirmation along with 80101 QW in an office setting? Appreciate your response please.

  6. #6
    Smile
    Quote Originally Posted by vazq123 View Post
    As of 2010 Medicare requires the use of G0434 for low-moderate complexity (cups/strips) and G0431 for high complexity (analyzer), each can only be billed with 1 unit, regardless of how many classes are screened. The G0434 allows approx $20 and the G0431 approx $100, depending on the MAC/FI.
    QW modifier is used to indicate the test was CLIA waived.
    Some Medicaid and WC carriers have followed MDCRs lead and are requiring these HCPCS also, varies from state to state. These can be confirmed on the MDCD/WC websites through their fee schedules and/or medical policies.
    Commercial carriers as of right now are accepting the CPT codes of either ; 80101 (qualitative single class) or 80104 (qualitative multiple class, per procedure).
    Which are accepted and how they will allow you to bill, are individually determined.

    It is never a good idea to "hit or miss" claims. That sends red flags to carriers that best practices are not being followed. The idea is to get your claims out "clean" the first time. That will require research and due dillignece with each of your major carriers, maintaining up to date policies and staying on top of any upcoming changes. Initially, that all takes time to get it down pat, but the payoff in the long run is well worth it. Quick turn arounds from claim release date to payment, which equals low A/R, happy physicians/clinicians, and you as a valuable, well regarded, well compensated, employee....
    I have a question regarding this: If I bill this as 80101 x12 to a commercial insurance do I need to indicate anywhere on the claim which drug or class I'm screening for? I'm having difficulty locating information for this code w/ my carrier as far as a policy. Any advice or reference would be appreciated. Thank you,

  7. #7
    Location
    St. Joseph County, Indiana
    Posts
    101
    Default
    No, you do not need to indicate which drug classes you are billing for Medicare or commercial carriers. You just need to have documentation in patient's chart.

    Brock Berta, CPC-A
    Billing Czar

  8. #8
    Location
    St. Joseph County, Indiana
    Posts
    101
    Default
    Also, Charisma,

    It is generally NOT allowed to bill in a physician's office for a qualitative screen AND a confirmation. The qualitative confirmation is meant to be used by labs as a tool to assist in their quantitative tests.

    Brock Berta, CPC-A
    Billing Czar

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