Toxicology Testing: New Codes for 2011
By: Justin Vaughn, CPC, M.Div
Director of Compliance
12/20/2012

For those of you who have added, or are planning to add, a drug screening component to your pain practice, there are new rules for 2011 you will want to note.  The AMA and CMS have implemented important changes in the urine toxicology code sets that are meant, in part, to clear up uncertainties in the 2010 code descriptors and in appropriate billing protocols. 

A summation of these changes is provided as follows:

•    CMS has deleted code G0430, “Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure,” from the fee schedule.

•    CMS has revised the descriptor for G0431 to now read, “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.”  Because this is a “per patient encounter” code, you may only bill one unit for this screening procedure regardless of the number of dipsticks employed during the session.  However, CMS has set the reimbursement for this code at five times the rate for the deleted code, G0430.  This is due to CMS research revealing that “a multiplier of five (5) accurately represents the average number of confirmatory tests that might be required from one specimen.”  Finally, unless you have a “complex lab” (as implied by the “high complexity” requirement in the code descriptor), you should not submit this code to Medicare. 

•    CMS has created a new code, G0434, “Drug screen, other than chromatographic; any number of drug classes by CLIA waived test or moderate complexity test, per patient encounter.”  This code is essentially meant to replace deleted code G0430, and will be paid at a similar rate.  Again, due to the “per patient encounter” part of the descriptor, you may not bill multiple units when submitting G0434 on the claim form.   

•    The AMA has created a new code, 80104, “Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure.” 

•    Medicare will not recognize 80100 or 80104.  Instead, providers would use G0431 or G0434.

We anticipate that further clarification in the use of these codes will be released by the AMA, CPT and/or CMS in the weeks ahead.  We will continue to keep you updated as more information become available.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.