CMS Clarifies Drug Screen Codes
By: Justin Vaughn, M.Div, CPC
Director of Compliance

2/25/2011

Pain physicians who perform urine toxicology tests are often bewildered by the seemingly endless changes in Medicare and CPT coding protocols, as well as the continuing lack of clarity in official guidance concerning these codes.  In a recently released MLN Matters article (# SE1105), CMS has attempted to shed a little more light on the appropriate circumstances under which two of the key drug screen codes would be submitted to Medicare.  The pertinent points arising from the article are as follows:

Code G0434

This code “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.”

Code G0431

This code “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).

• “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.”

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.