# quantitative drug testing



## jeancpc (Apr 3, 2014)

I code and bill for a Pain Clinic, can anyone advise me on how to code and bill "Quantitative Drug Testing" for multiple drug classes.  Thanks for any help...


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## dwaldman (Apr 3, 2014)

I would review the below from Palmetto, they are stating certain in-office instruments create a semi-quantitative and should not be billed using quantitative codes. Additionally, routine performance of quantitative testing would be subject post payment review and potentially in-depth audits.


Within the AMA CPT Manual they have a chart with the different drugs and their quantative code. I copy and pasted a list I found that has quan. testing codes but did not cross check if these are current. The Medicare LCD has specific guidelines for billing. Such as it would not be appropriate to do a quantative screen for a drug/drug class that tested negative with the initial qualitative screen. I think that is important point. And the fact is there an order for quantative screen and what documentation on positive screen will the quantative result yield as a better understanding of how to manage the patient. 



http://www.palmettogba.com/palmetto...edicare~Articles~Drugs Biologicals~8Q2LHW8528




  Railroad Medicare 
Semi-Quantitative Drug Testing: Billing/Coding Alert



Pain Management Billers:
If you are a point-of-care provider that bills services to monitor drugs of abuse and submits a quantitative code, you may be at risk for an overpayment request. 

In order to effectively treat chronic pain, physicians rely on drug testing to monitor prescribed medications and drugs of abuse. Practices may purchase or lease enzyme immunoassay (EIA) devices to provide preliminary qualitative or semi-quantitative test results for monitoring purposes. EIA devices and the reagents used to perform in-office drug testing are FDA cleared only to obtain qualitative or semi-quantitative initial screen/preliminary results. 

Since an immunoassay and an enzyme assay are by definition moderate complexity tests that produce qualitative and semi-quantitative results, they may not be reported with a quantitative code. Confirmation or quantification of the preliminary result is not usually produced in a point-of-care setting. 

The initial drug screen/preliminary result should be reported with HCPCS code G0434, (Drug screen other than chromatographic; any number of drug classes), by CLIA waived test or moderate complexity test, per patient encounter.

The following codes should not be reported for the initial screen/preliminary result when performed by EIA:
?HCPCS code G0431 ? Drug screen, qualitative; multiple drug classes by high complexity test method 
?CPT Chemistry section, codes 82000-84999 
?CPT Drug Testing section, codes 80100-80104 
?CPT Therapeutic Drug Assays section, codes 80150-80299 

Use of the above codes to report preliminary qualitative or semi-quantitative test results is considered systematic up-coding and may lead to criminal and civil penalties.

If you believe your practice has made this error, it may be in your best interest to take the following actions: 
?Complete a self-audit ◦Identify incorrect submissions 
◦Contain further claim submission errors 

?Consider self-disclosure protocol ◦Self-disclosure guidelines available on the OIG website 



Below is from WPS Medicare J5

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. Also eliminated by confirmation is the risk of a ?pill scraper? slipping through. Patients diverting their drug attempt to cheat the test by scraping a bit of drug from a pill into their urine sample. It would screen positive, but there would be no metabolite upon confirmation. Frequent use of this code will be monitored for appropriateness.
_________________________________________________________

Alcohol Metabolites (EtG/EtS) Confirmation 82055 
Amphetamines Confirmation 82145 
Barbiturates Confirmation 82205 
Benzodiazepine Confirmation 80154 
Cannabinoids/THC Confirmation 82542 
Carisoprodol/Meprobamate Confirmation 83805 
Cocaine Metabolite Confirmation 82520 
Fluoxetine Confirmation 80299 
Gabapentin Confirmation 82491 
Methadone Confirmation 83840 
Methylphenidate Confirmation 82491 
Opiates Confirmation 83925 
     Buprenorphine Confirmation 83925 
     Fentanyl Confirmation 83925 
     Propoxyphene Confirmation 83925 
     Tapentadol Confirmation 83925 
     Tramadol Confirmation 83925 
Phencyclidine Confirmation 83992 
Pregabalin Confirmation 82542 
Sertraline Confirmation 80299 
Tricyclic Antidepressants Confirmation  
     Amitriptyline Confirmation 80152 
     Cyclobenzaprine Confirmation 80299 
     Desipramine Confirmation 80160 
     Doxepin Confirmation 80166 
     Imipramine Confirmation 80174 
     Nortriptyline Confirmation 80182 
Zaleplon Confirmation 80299 
Zolpidem Confirmation 80299 
Zopiclone/Eszopiclone Confirmation 80299 

Imipramine Cutoffs

Drug Cutoff CPT Code 
Imipramine 25 ng/ml 80174


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## jeancpc (Apr 7, 2014)

Thank you so much for the information and link to Palmetto.  This answers a lot of my questions


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## jaimzey@gmail.com (May 2, 2014)

Jean,

Can I email you a copy of the results of a patient that our facility is testing (we are a Pain Management facility).  If so, can you advise me on how to code this out?  I've researched and researched and can NOT get a conclusive answer.  I am new to coding and also I have been coding ortho and spinal procedures...this is way out of my league.

Thank you for any advise you can give me ...

Jaimzey@americanspinemd.com


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## dwaldman (May 10, 2014)

I found the below from Andor Labs and thought it was interesting regarding the different types of testing, specifically semi-quantitative versus quantitative screening.


What is the difference between qualitative, semi-quantitative screening and quantitative drug confirmation?


QUALITATIVE URINE DRUG SCREENING

Qualitative Urine Drug Screening is performed routinely at the collection facility using a commercial urine collection cup. Up to 12 drug classes can be assessed from a single collection, depending on the brand of collection cup employed. Qualitative Urine Drug Screening tests provide Positive/Negative (Yes/No) responses. Each testing panel on the collection cup is impregnated with (bio)chemical reagents that respond to the presence of drugs from a specific drug class. When there is a sufficient amount of drugs from the class present, the panel will change color to indicate the drugs are present. The specific drug or drugs that contribute to the positive response cannot be identified through Qualitative Urine Drug Screening. It should be understood that some drugs unrelated to the drug class being assessed with Qualitative Urine Drug Screening may lead to a false positive result. Alternatively, adulterants may mask the response of drugs that are present and lead to a false negative result.

Positive responses during Qualitative Urine Drug Screening provide a preliminary assessment of the types of drugs that may be present in the urine at the time of collection. To identify the drugs that caused the positive response or to determine if a specific drug is present at a concentration below the amount that triggers the response, Quantitative Urine Drug Confirmation Testing should be employed.

SEMI-QUANTITATIVE URINE DRUG SCREENING

Semi-Quantitative Urine Drug Screening is an alternative to Qualitative Urine Drug Screening. Semi-Quantitative Urine Drug Screening is performed using an auto-analyzer typically found in clinic, hospital and toxicology laboratories. Again, a wide variety of drug classes can be assessed from a single collection, depending on how the auto-analyzer is programmed. Semi-Quantitative Urine Drug Screening tests provide numerical results related to the summed concentrations of drugs within a specific class that are present in the sample. As with Qualitative Urine Drug Screening, Semi-Quantitative Screening utilizes (bio)chemical reagents that respond to the presence of drugs from a specific class. However, for Semi-Quantitative Screening, the response generated is based on instrument calibration. Calibration is the relationship between responses generated by a compound representative of the drug class at different concentrations (i.e., concentration-response). The numerical result represents the summed concentrations from all drugs in the class that contribute to the response. For instance, the numerical result generated by the Semi-Quantitative Screening test for Opiates includes the summed contributions from Morphine, Codeine, Hydrocodone, Hydromorphone, and to a lesser extent, Oxycodone and Oxymorphone. The specific drug or drugs that contribute to the positive response cannot be identified through Semi-Quantitative Urine Drug Screening.

Importantly, not all forms of a drug elicit a response and not all drugs lead to the same response. Drugs may be present in urine as the original drug compound or as drug metabolites; metabolites are chemically related to the original drug compound but may or may not lead to an instrument response. For instance, benzodiazepine drugs are found in urine primarily as drug-glucuronide metabolites of the original drug compound: drug-glucuronide metabolites do not trigger a response. Thus, although there may be a high concentration of benzodiazepine drug-glucuronide present the urine, the concentration of the original drug compound is insufficient to trigger a response.

A numerical response during Semi-Quantitative Urine Drug Screening provides a preliminary assessment of the type and concentration of drugs that may be present in the urine at the time of collection. To identify the drugs that caused the numerical response or to determine if a specific drug is present at a concentration below the amount that triggers the response, Quantitative Urine Drug Confirmation Testing should be employed. As with Qualitative Urine Drug Screening, some drugs unrelated to the drug class being assessed may lead to a false response and adulterants can mask the response of drugs that are present yielding a false negative result.

QUANTITATIVE URINE DRUG CONFIRMATION TESTING

Quantitative Urine Drug Confirmation Testing provides definitive proof of the presence and concentration of specific drugs in a urine collection. It is used to define further the results of Qualitative or Semi-Quantitative Urine Drug Screening. Quantitative Urine Drug Confirmation Testing is typically performed using gas chromatography (GC) or, in recent years, liquid chromatography (LC) to separate the drugs within a urine sample prior to detection using mass spectrometry (MS). GC/MS and LC/MS instrument systems are found in hospital and toxicology laboratories and must be operated by skilled personnel. 

GC/MS and LC/MS instruments are sensitive; that is, they can detect drugs present at concentrations far below the cutoff values for Qualitative and Semi-Quantitative Drug Screening. GC/MS and LC/MS instruments are specific; that is, they can identify individual drugs and drug metabolites present in a sample containing multiple drugs. For instance, drugs commonly included in an Opiate panel are Morphine, Codeine, Hydrocodone, Hydromorphone, Oxycodone and Oxymorphone. The presence/absence of each drug in the class can be confirmed as well as the concentration of each determined simultaneously. 

Positive identification is made by the order the drugs enter the mass spectrometer from the liquid chromatographic system and by the mass (e.g., molecular weight) detected by the mass spectrometer in relation to the order and mass of a known amount of a related compound (i.e., internal standard). Similar to Semi-Quantitative Screening, a concentration-response calibration must be performed for each drug to be quantified accurately. Only drugs that are calibrated will be identified and quantified; other drugs within the class that are present but are not calibrated will not be detected. For instance, if Benzoylecgonine (the major metabolite of Cocaine) but not Cocaethylene (a Cocaine metabolite produced only when the patient has consumed alcohol in addition to Cocaine) is calibrated, only Benzoylecgonine will be identified and quantified. Even though Cocaethylene may be present, it will not be detected.

Importantly, a urine specimen can be pretreated prior to MS detection to remove substances that can interfere with detection and/or to convert drug metabolites to the original drug form. This provides for increased specificity and sensitivity and, thus, more confidence in results.


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## JohnBox (Dec 17, 2015)

*Quantitative urine drug confirmation testing*

Should you only bill out the positive confirmation codes and not the negative ones to the carrier. Also when it is a positive confirmation can you bill out for each metabolite under that drug class using a modifier 59.


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## dwaldman (Dec 20, 2015)

JohnBox, I believe this concept of performing a definitive test/quantitative drug test for a specimen that might of been initially negative when tested in an presumptive/immunoassay format, or test is complete definitive without initial presumptive test would fall under the interpretation of carrier you are billing guidelines. 

For the metabolites, it important to note the new codes for 2016 state "including metabolites when performed"


https://www.aapc.com/blog/32826-cms-...s-corrections/

 G0477 l Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 

 G0478 Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 

 G0479 Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service 

 G0480 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed 

 G0481 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed 

 G0482 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed 

 G0483 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed


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## Jo Burt (Feb 23, 2016)

*Medicare/Novitas Urine Drug Screen Testing*

I work for a pain management clinic in Houston, Texas and we are having our UDS's denied.  We are using the new code G0477QW with diagnosis Z79.891.  Can anyone tell me why these are being denied for; Procedure is inconsistent with the modifier used or required modifier is missing.  I have also heard that Medicare is holding the payment of this code until April 1???  Any help in this would be greatly appreciate.


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## CodingKing (Feb 23, 2016)

Jo Burt said:


> I work for a pain management clinic in Houston, Texas and we are having our UDS's denied.  We are using the new code G0477QW with diagnosis Z79.891.  Can anyone tell me why these are being denied for; Procedure is inconsistent with the modifier used or required modifier is missing.  I have also heard that Medicare is holding the payment of this code until April 1???  Any help in this would be greatly appreciate.



CLIA waiver has not been implemented yet, supposed to be by 4/1/16 and I believe its retro to 1/1/16


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## Walker22 (Feb 23, 2016)

CodingKing said:


> CLIA waiver has not been implemented yet, supposed to be by 4/1/16 and I believe its retro to 1/1/16



This is correct.


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## kmcdowell@pfcadocs.com (May 20, 2016)

*Uhc mcr drug code*

I work for a family practice and UHC MCR ADVANTAGE plans are denying the G0477 code from Feb.  When I call they tell me it is not a reimbursable code with them. Can anyone help?


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## Walker22 (May 20, 2016)

kmcdowell@pfcadocs.com said:


> I work for a family practice and UHC MCR ADVANTAGE plans are denying the G0477 code from Feb.  When I call they tell me it is not a reimbursable code with them. Can anyone help?



Try 80300. Not all insurances have adopted the G codes.


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## KMCFADYEN (May 20, 2016)

UHC Medicare Advantage should accept the G0477 but it does require QW modifier.
There are a select few insurance companies, USDOL being one, that will not accept the G code and you will have to bill 80300 without the QW modifier.


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