# 80101,80104,g0431,g0434



## Lydia Helmholz (Mar 15, 2011)

I cannot find coding/billing rules on CMS, can anyone refer me to site for coding and billing instruction?

Thanks


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## margieclark (Mar 16, 2011)

We are struggling with this same issue.  A medicare representative pointed me to this website.     http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage 
I'd love to hear what other providers are finding as they investigate also.


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## vazq123 (Mar 21, 2011)

MUEs are very helpful, however this might help also:

http://www.cms.gov/ClinicalLabFeeSched/Downloads/CY2011-CLFS-New-Test-Codes.pdf

Last Modified: 3/4/2011 Location: FL, PR, USVI Business: Part A, Part B :

Clinical laboratory fee schedule -- removal of test code G0431QW and addition of test code G0434QW
The Centers for Medicare & Medicaid Services (CMS) is updating the status of two codes on the clinical laboratory fee schedule (CLFS):
• Effective immediately, code G0431QW is deleted from the CLFS. Code G0431 describes a high complexity test, and should not be reported with a QW modifier; the QW modifier indicates a CLIA waived test.
• Effective immediately, code G0434QW is added to the CLFS. Code G0434 can describe a CLIA waived test. The use of the QW modifier to indicate a CLIA waived test is necessary for accurate claims processing.
Codes G0431 and G0434 will remain on the CLFS. 


For 2011, G0431 is for high complexity testing and CMS has increased the allowance times five to be billed at 1 unit. The average fee, depending on the intermediary, is somewhere around $100 now. G0434 is to be used for low to med complexity testing and billed at 1 unit, the rationale being once per patient,per encounter, with an average allowance of $20. 

When billing commercial carriers for point of care testing, it's best to contact each carrier to clarify what their medical and/or billing policies are. Most cariers will have their policies available to view online. Depending on what state you're in and which carrier you're billing, will determine what and how you bill. A lot of carriers are not recognizing 80104 yet, then you have carriers that do not allow either 80101 or 80104 ( some Blues).
As for MDCR in office testing, the newest update (link above) does to a better job of explaining the rationale for the newest code changes and when it is appropriate to use which code. 

The following is an exceprt from the updated G0434 rationale:

*This reflects the fact that in any given patient encounter, no matter how many drugs of abuse tests are performed and no matter whether these tests are CLIA waived (simple dipstick test kit) or moderate complexity (reader outside the laboratory setting), proper billing would be one time per patient.

The same goes for using the QW modifier outside of MDCR,it is on a carrier by carrier basis on whether it is needed and only they can answer that question.


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## LuluBarr (May 2, 2011)

What to do in the case of Blue Cross denying 80101 and not recognizing 80104? I billed 80101 and it was denied as a non covered service and made pt responsibilty. I thought to send a corrected claim with the new code 80104 but I see that Anthem doesn't have it on their fee schedule either. What is going on? What can I do?


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## LuluBarr (May 3, 2011)

will medicare and private insurances completely disallow G0431 and 80101? What if we do testing using a single test device?


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## m.j.kummer (May 3, 2011)

vazq123 said:


> MUEs are very helpful, however this might help also:
> 
> http://www.cms.gov/ClinicalLabFeeSched/Downloads/CY2011-CLFS-New-Test-Codes.pdf
> 
> ...



Great information to have.  Thanks for sharing.


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## brockorama01 (Jun 27, 2011)

LuluBarr,

Anthem (in Indiana) does have a fee schedule for both 80101 and 80104.   

Are you still having problems?

Brock Berta, CPC


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