CPT Codes 80100-80101, 80102

August 15th, 2012 -

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Drug Testing

UDT may be appropriate in the clinical settings for various reasons, including but not limited to chronic pain management and addictionology. UDT should not routinely include a panel of all drugs of abuse. The test ordered should be focused on detecting the specific drug(s) of concern. Frequency of testing should be at the lowest level to detect the presence/ absence of drugs of concern bearing in mind the pharmaco-dynamics for which the drug is being screened.

The accepted method of urine drug screening for a patient with poly-substance abuse during a monitoring period is by utilization of a multi-drug screening kit. (Qualitative analysis by multiplexed method for 2-15 drugs or drug classes). These services may be  performed within the provider office and/or sent to a reference lab using the codes: 80100, 80101, 80102, 80104, G0431 and G0434 (payer specific policies).

Drugs or drug classes for which screening is performed should reflect only those likely to be present, based on the patient’s medical history or current clinical presentation. Drugs for which specimens are being screened must be indicated by the referring provider in a written order.

80100 – Drug screen, qualitative; multiple drug classes chromatographic method, each procedure*. This CPT code is to be used to report all multiple drug class assays employing chromatographic methods. It can be reported once for each procedure (i.e. unique combination of stationary and mobile phase) employed.

CPT instructions: “Use 80100 for each multiple drug class chromatographic procedure”. For chromatography, each combination of stationary and mobile phase is to be counted as one procedure. For example, if detection of three drugs by chromatography requires one stationary phase with three mobile phases, use code 80100 three times (x3). However, if multiple drugs can be detected using a single analysis (eg, using one stationary phase with one mobile phase), use 80100 only once (x1).

Code 80100 has not been priced under Medicare effective January 1, 2011.

Code 80104 has not been priced under Medicare effective January 1, 2011.

CPT code 80101 has not been priced under Medicare since July 1, 2010.

The following CPT codes are Non-Covered by Medicare

80100 DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES CHROMATOGRAPHIC METHOD, EACH PROCEDURE; 80101 DRUG SCREEN, QUALITATIVE; SINGLE DRUG CLASS METHOD (EG, IMMUNOASSAY, ENZYME ASSAY), EACH DRUG CLASS

80101- Effective April 1, 2010, CPT code 80101 will no longer be covered by Medicare, and CPT code 80101-QW will be deleted. New test code G0431 is a direct replacement for CPT code 80101. For purposes of the CLFS (Clinical laboratory fee schedule), effective with dates of service on or after April 1, 2010, test code G0431 should be utilized by those clinical laboratories that do not require a CLIA certificate of waiver. Those clinical laboratories that do require a CLIA certificate of waiver should utilize
test code G0431-QW.

G0434- Effective January 1, 2011, drug screen testing:

G0434 (Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter) will be used to report very simple testing methods, such as dipsticks, cups, cassettes, and cards, that are interpreted visually, with the assistance of a scanner, or are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code is also used to report any other type of drug screen
testing using test(s) that are classified as Clinical Laboratory Improvement Amendments (CLIA) moderate complexity test(s), keeping the following points in mind: G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc, that are not CLIA waived.

Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver shall bill using the QW modifier.

Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests.

Laboratories with a CLIA certificate of compliance or accreditation do not append the QW modifier to claim lines.

Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines.

Codes that describe “once per patient encounter” are only eligible for 1 unit of service per patient encounter, regardless of the number of procedures performed.

Term: Point of collection (POC) testing (often called dip stick testing).

Examples of drugs or drug classes that are commonly assayed by qualitative tests include, but are not limited to, the following: amphetamines(AMP), barbiturates/sedatives(BAR), benzodiazepines(BENZ), cocaine and metabolites (COC), cannabinoids(THC), methadone(METH), antihistamines, stimulants, opioid analgesics(OP), salicylates, cardiovascular drugs, antipsychotics, and cyclic antidepressants.

G0431 (Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter) will be used to report more complex testing methods, such as multi-channel chemistry analyzers, where a more complex instrumented device is required to perform some or all of the screening tests for the patient. Note that the descriptor has been revised for CY 2011. This code may only be reported if the drug screen test(s) is classified as CLIA high complexity test(s) with the following restrictions:

G0431 may only be reported when tests are performed using instrumented systems (i.e., durable systems capable of withstanding repeated use).

At this time, the national code pair edits indicate that G0431 would not conflict with CPT 80102, and, therefore, it appears that G0431 is not currently identified as a replacement code for 80102.

CLIA waived tests and comparable non-waived tests may not be reported under test code G0431; they must be reported under test code G0434.

CLIA moderate complexity tests should be reported under test code G0434 with one (1) Unit of Service (UOS).

G0431 may only be reported once per patient encounter.

Laboratories billing G0431 must not append the QW modifier to claim lines.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1105.pdf

Qualitative drug screening tests are used to detect the presence of a drugs or drug classes in the body. They provide a positive or negative result rather than specific measurements of the level of a drug or drugs. Methods of collecting/testing include, but are not limited to:

• Cassettes
• Cubes
• Cups
• Dip cards
• Strips
• Swabs

A procedure is defined as a single device or separate set of reagents, using an instrument, to produce one or more test results.

Confirmation of drug testing (80102) is indicated when (1) the results of the qualitative screen are presumptively positive or (2) results of the qualitative screen are negative and this negative finding is inconsistent with the patient's medical history. This test may also be used, when the coverage criteria of the policy are met AND there is no qualitative test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids.

A positive qualitative screen often results in an inadequate result upon which to make a proper determination. A more specific method, such as gas or liquid chromatography coupled with mass spectrometry, may be needed in order to obtain a confirmed analytical result. In particular, qualitative screens are frequently inadequate for interpretation of opiate and benzodiazepine results; quantitative testing may be needed in these instances. Confirmation testing is usually not required for drugs like methadone, wherein false positive results are rare. However, factors such as cross-reactivity with other similar compounds or interfering substances in the specimen. Confirmatory testing eliminates the risk of false positives.

Confirmation of drug screens (80102) is indicated when the result of the drug screen is different than that suggested by the patient’s medical history, clinical presentation or patient’s own statement.

General Information

Documentations Requirements

1. All documentation must be maintained in the patient's medical record and available to the payor upon request.

2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the identity of the physician or non-physician practitioner responsible for and providing the care of the patient.

3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.

4. Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering physician/treating physician must indicate the medical necessity for performing a qualitative drug test. All tests must be ordered in writing by the treating provider and all drugs/drug classes to be tested must be indicated in the order.

5. If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the lab results, along with copies of the ordering/referring physician's order for the qualitative drug test. The physician must include the clinical indication/medical necessity in the order for the for the qualitative drug test.

Remember (Medicare)

Code of Federal Regulations:

42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified nonphysician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1)).

Medicare

In all cases, drugs or drug classes for which testing is performed, should reflect only those likely to be present, based on the patient's medical history, current clinical presentation, and illicit drugs that are in common use. In other words, it is NOT medically necessary or reasonable to routinely test for substances (licit or illicit), which are not used in the patient treatment population or, in the instance of illicit drugs, in the community at large. Drugs for which specimens are being tested must be indicated by the referring provider in a written order.

Focused drug screens, most commonly for illicit drug use may be more useful for immediate or temporary clinical decision making to support continuation or discontinuation of a treatment plan.

In addition routine confirmation (quantitative) of drugs screens with negative results is not covered by Medicare. Confirmatory testing is covered for a negative drug/drug class screen when the negative finding is inconsistent with the patient’s medical history or current documented chronic pain medication list.

Summary:

These codes are to be submitted for commercial payers: – not covered for Medicare and Medicaid (verify with individual Medicaid Carriers).

Note: There are private payers that have adopted the G codes.

CPT 80100 Drug screen, qualitative; multiple drug classes chromatographic method, each procedure

Use 80100 for each multiple drug class chromatographic procedure.

• For chromatography, each combination of stationary and mobile phase is to be counted as one procedure. (If multiple drugs can be detected using a single analysis, [one stationary with one mobile phase] report 80100 once.)
• If detection of three drugs by chromatography requires one stationary phase with three mobile phases, report CPT 80100 three times.

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

• Billable with a count of one for each single drug class method/each drug class, capped at a maximum of 5 units per date of service (some payors, more or less). (For qualitative analysis by multiplexed screening kit for multiple drugs or drug classes, use CPT 80104).

CPT 80104 Drug screen, qualitative; multiple drug classes other than chromatographic method, each
procedure

• Submit to report a specific drug screen, qualitative analysis by multiplexed method for 2-15 drugs or drug classes (e.g., multidrug screening kit). Bill once with a count of 1.
• Use 80104 to report a specific drug screen, qualitative analysis by multiplexed method for 2-15 drugs or drug classes (e.g. multidrug screening kit).

Resources

http://legalsideofpain.com/uploads/Palmetto-DL32597-NoCAL(1).pdf

http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=3358

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html?
redirect=/ClinicalLabFeeSched

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