# Urine Drug Screens



## kseeg23

For 2015 we have new codes for urine drug screens. My question is for CPT 80300, is the QW modifier needed? We've been applying it, but some insurances are saying it's invalid. Any help would be appreciated! Thanks!


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## dwaldman

Are they stating the modifier QW is invalid or they want G0434 instead and issue is with their coverage for 80300?

If it is a modifier issue and the carrier does not accept or require this particular modifier then the carrier would determine the modifiers they can accept for claims processing.

Below are some examples I found on an internet search regarding the use of "G" codes for drug testing for private payers.
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Aetna
Qualitative drug screen codes G0431& G0434 6/1/2012 
Starting 6/1/2012, the use of either G0431 or G0434 will be required for the billing of qualitative drug screens.  One unit of either code will be reimbursed per patient encounter, when qualitative testing methods are used.  Any billing of CPT codes 80100, 80101 or 80104 will be adjudicated according to this policy with appropriate mapping to one unit of G0431 or G0434 per patient encounter. 
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Updates to Cigna's Qualitative Drug Screen Testing Code Edits
May 20, 2013


Cigna will be updating their Code Edit Policy with guidelines for Qualitative Drug Screen Testing effective August 19, 2013. This policy is in accordance with recommended updates from the Centers for Medicare & Medicaid (CMS).  With this update, claims submitted under CPT codes 80100, 80101, and 80104 will no longer be reimbursed.        

CPT codes 80100, 80101, and 80104 should be submitted under the following HCPCS codes: 
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 highly complex testing methods ? such as multi-channel chemistry analyzers ? where a complex instrumented device is required to perform some or all of the screening tests for the patient. 
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 simple testing methods ? such as dipsticks, cups, cassettes, and cards ? that are interpreted visually with the assistance of a scanner, or are read using a moderately complex reader device outside the instrumented laboratory setting. 
Reimbursement for codes G0431 and G0434 will be limited to one unit per single date of service. 
Physicians should only bill for services that they perform themselves. The laboratory performing the tests should submit the claims, not the physician's office ordering the tests. 
To view these changes in Cigna's updated Code Edit Policy and Guidelines, log in to CignaforHCP.com and click on "Useful Links" and then "Claim Editing Policies & Procedures".  

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UnitedHealthcare

United Healthcare Requiring Alternative Codes for Drug Screening

11/22/2013

Beginning the first quarter of 2014, United Healthcare announced it will no longer reimburse CPT codes 80100, 80101 or 80104 for qualitative drug screening, and will align with the Centers for Medicare & Medicaid Services (CMS) requirement to use HCPCS codes G0431 and G0434 to report drug screening tests. ACCMA and CMA will inform members of the specific effective date of this change as soon as it becomes available. 

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Anthem BCBS
Anthem BC/BS Billing and Reimbursement Policy:

The Health Plan follows the Centers for Medicare & Medicaid Services (CMS) guidelines for reporting point of care qualitative drug screen testing in a physician's office. Therefore Current Procedural Terminology (CPT?) codes 80100, 80101, and 80104 are considered bundled services and will not be eligible for separate reimbursement by the Health Plan (Refer to Bundled Services and Supplies Policy). Qualitative drug screen testing is eligible for separate reimbursement only when reported with HCPCS codes G0431 (as replacement of CPT codes 80100 and 80101) and/or G0434 (as replacement of CPT code 80104). Both codes G0431 and G0434 will be eligible for one (1) unit of reimbursement per date of service. Use of code G0431 is limited to high complexity testing. As a condition of reimbursement, the Health Plan may require documentation of FDA-approved complexity level for instrumented equipment, and/or CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab.


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## kseeg23

As always....THANKS!!


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## careymvigor

*urine drug screens DATA2000*

I have been told by staff at WPS that we can appeal the one drug class per dsy rule for DATA2000 patients as the NIDA protocols support up to 13 drug classes as well as adulterants and a UA for each Rx of buprenorphine. I faxed them 91 pages of the NIDA protocol and am waiting for their written response. I will keep y'all posted.


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## beckycmbs

What did WPS say?


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## 2504mollie

*help*

can anyone please tell me if your internal med doctors are billing g0434 to medicare after 10/01/15 and getting paid? all of mine have been denied for medical necessity.


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## dwaldman

2504Mollie,

You mentioned the specialty of internal medicine where potentially this provider is wanting to conduct an in office drug test. I would review the local coverage determination policy on what the carrier in that state considers reasonable and necessary to make sure that their policy is understood and the diagnosis that meet medical necessity are documented within the order and patient visit encounter. I believe that in office test with drug test cup in 2016 will be around 8.5 to 14.8 dollars with the resources paired with appropriate reimbursement, I think if you review the Medicare LCD of your state, there might be coverage for this service for a patient with chronic pain for example as seen below with WPS Medicare J5.

D. Medicare will consider performance of a qualitative/presumptive drug test reasonable and necessary when a patient presents with one or more of the following conditions: 
1. For monitoring patient compliance during active treatment for substance abuse or dependence.

2. A drug screen is considered medically reasonable and necessary in patients on chronic opioid therapy:
- In whom illicit drug use, non-compliance or a significant pre-test probability of non-adherence to the prescribed drug regimen is suspected and documented in the medical record; and/or
- In those who are at high risk for medication abuse due to psychiatric issues, who have engaged in aberrant drug-related behaviors, or who have a history of substance abuse.

3. Medicare will consider performance of a drug test reasonable and necessary in patients with chronic pain to:
- determine the presence of other substances prior to initiating pharmacologic treatment 
- detect the presence of illicit drugs
- monitor adherence to the plan of care


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## KMCFADYEN

dwaldman, you are always on top of these questions.  
Many Medicare carriers (as well as other insurance companies) have an LCD for the urine drug screens.  Check the protocol and diagnosis.


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## tba123

80300 should not need the QW, some carriers when billing the old G0434 didn't even want the QW even though they wanted the G code.  

I have a question, what dx are you billing for your drug screens?  We have been billing the dx that goes with why the patient is on the narcotic, however some carriers are denying invalid dx, so I am thinking they want a monitoring code.  I had thought about Z51.81 but was unsure if this was for labs only. 

Thanks, Anna Sanders


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## dwaldman

Anna, I would review the Medicare local coverage determination policy for the geographical area you are located in, Medicaid policies, and other private payers to correlate the criteria for coverage with ICD-10 codes that most appropriately describe the patient circumstance which a drug test might be required in the course of  treatment. Below for example Z79.891 is described in WPS Medicare J5 local coverage determination policy for drug testing. Z79.891 containing the similar to code descriptor as previous ICD-9-CM code V58.69.

ICD-10 Codes that Support Medical Necessity 


Group 1 Paragraph: For monitoring of patient compliance in a drug treatment program, use diagnosis code Z03.89 as the primary diagnosis and the specific drug dependence diagnosis as the secondary diagnosis.
For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence use diagnosis code Z79.891, suspected of abusing other illicit drugs, use diagnosis code Z79.899.



Group 1 Paragraph: New Codes effective 01/01/2016


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

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

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

G0480 Drug tests(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 enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed. 

G0481 Drug tests(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 (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug classes (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 sterioisomers), 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, includes specimen validity testing, per day, 15-21 drug classes, including metabolites(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 sterioisomers), 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, includes specimen validity testing, per day, 22 or more drug classes, including metabolites(s) if performed. 


The following CPT codes are Non-Covered by Medicare


Group 1 Codes:

80300 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES FROM DRUG CLASS LIST A; ANY NUMBER OF NON-TLC DEVICES OR PROCEDURES, (EG, IMMUNOASSAY) CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION, INCLUDING INSTRUMENTED-ASSISTED WHEN PERFORMED (EG, DIPSTICKS, CUPS, CARDS, CARTRIDGES), PER DATE OF SERVICE 

80301 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES FROM DRUG CLASS LIST A; SINGLE DRUG CLASS METHOD, BY INSTRUMENTED TEST SYSTEMS (EG, DISCRETE MULTICHANNEL CHEMISTRY ANALYZERS UTILIZING IMMUNOASSAY OR ENZYME ASSAY), PER DATE OF SERVICE 

80302 DRUG SCREEN, PRESUMPTIVE, SINGLE DRUG CLASS FROM DRUG CLASS LIST B, BY IMMUNOASSAY (EG, ELISA) OR NON-TLC CHROMATOGRAPHY WITHOUT MASS SPECTROMETRY (EG, GC, HPLC), EACH PROCEDURE 

80303 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES, PRESUMPTIVE, SINGLE OR MULTIPLE DRUG CLASS METHOD; THIN LAYER CHROMATOGRAPHY PROCEDURE(S) (TLC) (EG, ACID, NEUTRAL, ALKALOID PLATE), PER DATE OF SERVICE 

80304 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES, PRESUMPTIVE, SINGLE OR MULTIPLE DRUG CLASS METHOD; NOT OTHERWISE SPECIFIED PRESUMPTIVE PROCEDURE (EG, TOF, MALDI, LDTD, DESI, DART), EACH PROCEDURE 

80320 - 80377 ALCOHOLS - DRUG(S) OR SUBSTANCE(S), DEFINITIVE, QUALITATIVE OR QUANTITATIVE, NOT OTHERWISE SPECIFIED; 7 OR MORE


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## AMANDACARLA

*fee-schedule*

dwaldman,

Where can I find the fee-schedule for those test you described?

Thanks

Isvel



ICD-10 Codes that Support Medical Necessity 


Group 1 Paragraph: New Codes effective 01/01/2016


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

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

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

G0480 Drug tests(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 enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed. 

G0481 Drug tests(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 (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug classes (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 sterioisomers), 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, includes specimen validity testing, per day, 15-21 drug classes, including metabolites(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 sterioisomers), 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, includes specimen validity testing, per day, 22 or more drug classes, including metabolites(s) if performed. 


The following CPT codes are Non-Covered by Medicare


Group 1 Codes:

80300 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES FROM DRUG CLASS LIST A; ANY NUMBER OF NON-TLC DEVICES OR PROCEDURES, (EG, IMMUNOASSAY) CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION, INCLUDING INSTRUMENTED-ASSISTED WHEN PERFORMED (EG, DIPSTICKS, CUPS, CARDS, CARTRIDGES), PER DATE OF SERVICE 

80301 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES FROM DRUG CLASS LIST A; SINGLE DRUG CLASS METHOD, BY INSTRUMENTED TEST SYSTEMS (EG, DISCRETE MULTICHANNEL CHEMISTRY ANALYZERS UTILIZING IMMUNOASSAY OR ENZYME ASSAY), PER DATE OF SERVICE 

80302 DRUG SCREEN, PRESUMPTIVE, SINGLE DRUG CLASS FROM DRUG CLASS LIST B, BY IMMUNOASSAY (EG, ELISA) OR NON-TLC CHROMATOGRAPHY WITHOUT MASS SPECTROMETRY (EG, GC, HPLC), EACH PROCEDURE 

80303 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES, PRESUMPTIVE, SINGLE OR MULTIPLE DRUG CLASS METHOD; THIN LAYER CHROMATOGRAPHY PROCEDURE(S) (TLC) (EG, ACID, NEUTRAL, ALKALOID PLATE), PER DATE OF SERVICE 

80304 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES, PRESUMPTIVE, SINGLE OR MULTIPLE DRUG CLASS METHOD; NOT OTHERWISE SPECIFIED PRESUMPTIVE PROCEDURE (EG, TOF, MALDI, LDTD, DESI, DART), EACH PROCEDURE 

80320 - 80377 ALCOHOLS - DRUG(S) OR SUBSTANCE(S), DEFINITIVE, QUALITATIVE OR QUANTITATIVE, NOT OTHERWISE SPECIFIED; 7 OR MORE[/QUOTE]


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## dwaldman

Amanda Carla, 

You can access the fee schedule for the new 2016 codes at the below link:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html


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## AMANDACARLA

dwaldman said:


> Amanda Carla,
> 
> You can access the fee schedule for the new 2016 codes at the below link:
> 
> https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html



Thank you so much.

Isvel


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