# HELP! 2016 in house drug screen g0477



## aziemianin (Jan 25, 2016)

Help!

Medicare along with other insurance companies are not paying the new G0477 in house drug screen code. Anyone having same issue?


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## Walker22 (Jan 25, 2016)

What is their denial reason? Knowing that would help you determine how to proceed.


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## Tgarner2016 (Jan 27, 2016)

I am having the same issue. The denial reason is missing CLIA certification. I dealt with this last year with Medicare. Humana is just saying its the contractual adjustment and not paying anything.


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## ckeeney (Jan 27, 2016)

I just found documentation on this yesterday. There is a CMS transmittal/change request that states the types of CLIA certification you must have for Medicare to pay this. Search for Transmittal 3439 dated January 15, 2016 for information from CMS on this code. The code is not CLIA waived (no QW modifier) so you must have the proper CLIA certification to be reimbursed for this.


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## aziemianin (Feb 3, 2016)

Thanks for getting back with me! So do you have the CLIA cert code 340 on your certification?


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## aziemianin (Feb 3, 2016)

CLIA Certification Code Missing or Invalid.


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## jkyles@decisionhealth.com (Feb 6, 2016)

aziemianin said:


> CLIA Certification Code Missing or Invalid.



CMS has placed a hold on all claims that include a drug screen code until April 1. 

https://www.cms.gov/Outreach-and-Ed...ive-Items/2016-01-28-eNews.html#_Toc441643998

Any claim that includes any drug screen code will not be processed until then.

I do know that the 2016 clinical lab fee schedule did not have a QW modifier for G0477, which I thought was odd at the time.


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## carlyjo82 (May 9, 2016)

ckeeney said:


> I just found documentation on this yesterday. There is a CMS transmittal/change request that states the types of CLIA certification you must have for Medicare to pay this. Search for Transmittal 3439 dated January 15, 2016 for information from CMS on this code. The code is not CLIA waived (no QW modifier) so you must have the proper CLIA certification to be reimbursed for this.



  I am having the same issue with G0477 being billed in a physician office setting with or without the QW.  My provider office has a CLIA waiver, but now, in order to do in office testing, they have to be CLIA certified?  Is this true with private payers as well?  Any information would be greatly appreciated!  Thank you very much!


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## Walker22 (May 10, 2016)

carlyjo82 said:


> I am having the same issue with G0477 being billed in a physician office setting with or without the QW.  My provider office has a CLIA waiver, but now, in order to do in office testing, they have to be CLIA certified?  Is this true with private payers as well?  Any information would be greatly appreciated!  Thank you very much!



CMS fixed this issue at the beginning of April. A CLIA waiver is all you should need.


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## carlyjo82 (May 11, 2016)

Walker22 said:


> CMS fixed this issue at the beginning of April. A CLIA waiver is all you should need.



Do we need to have Medicare reprocess all of the G0477 codes that they have denied since April 1st?  Is this true with other payers that they will recognize the g0477 as a "waived" test and allow us to still be reimbursed for it?


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## Walker22 (May 11, 2016)

carlyjo82 said:


> Do we need to have Medicare reprocess all of the G0477 codes that they have denied since April 1st?  Is this true with other payers that they will recognize the g0477 as a "waived" test and allow us to still be reimbursed for it?



Medicare has stated that they will reprocess all claims denied because of the CLIA issue. Of course, if there is some other reason for denial, those will not be reprocessed. As for the commercial payers, each one is different. You will likely have to contact them individually and work those claims.


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## tswitzer (Jan 24, 2017)

*G0477  HCPCSS vs 80305 CPT*

I have a new question regarding this issue. The G0477 code according to Medicare and Optum Encoder 360 Tool is discontinued as of 01/01/17. However the current HCPCS book says it is a valid code. Does anyone have any information on this. How do I found out what is correct? I have been told that 80305 a new CPT code is the replacement by our Medicare biller here at the hospital but because G0477 is still listed as active with HCPCS we are trying to figure out what the proper path is to proceed upon. I also noted in some of the previous responses that the modifier QW is/was not proper to append to the G0477 on dates before 01/01/17 is this correct?


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## Tgarner2016 (Jan 31, 2017)

We had to put the QW modifier to the G0477 code to get paid in 2016. Now from what I understand the code 80305 replaces G0477. For Medicare they are denying as an invalid code but Humana/Cigna are denying the G0477. I don't think Medicare is on board with these changes. Can someone help and point in the right direction? It seems like every year I have this same problem.


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## smbllc (Jan 31, 2017)

*80305 Modifer QW Yes Or NO*

Hello,
I know Medicare has stated that 80305 has replaced the G0477 effective 1/1/2017, but the PDF says its effective date is April 1 2017 just like they did last year when G0477 started and I do remember that having an effective date of April 1, 2016. I have billed Medicare with 80305 and added QW modifer and I am being denied. Has anyone billed with NO modifer and gotten paid? I know the modifer will be in place after April 1st, 2017 just not sure if it will still deny or if they will come back and pay them later if I bill it without the Modifier until April.  

My denial reason from Medicare when billing 80305 QW:  The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/Downloads/MM9956.pdf


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