Pain Management Coding Alert

Here’s a look at the codes that now include specimen validity testing.

Pain management practices need to note the newest version of the Correct Coding Initiative (CCI), as it contains important new bundles that could affect your lab test coding.

For an explanation on how these edits might affect your claims, we checked in with Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver, Co. Here’s her take on CCI 22.1.

CCI Bundles Validation Services Into G Codes

CCI 22.1, which took effect April 1, includes the following bundling edits for HCPCS codes:

• G0477 (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., dip sticks, cups, cards, cartridges], includes sample validation when performed, per date of service) through
• 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).

Many of the lab codes that you might report for specimen validity testing are now bundled into the codes in the G0477-G0483 set, says Hammer.

Example: When your provider performs a G0477 drug test that includes testing the urine specimen for pH, specific gravity, and/or nitrites for the same patient in the same session, you cannot report 81002 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) with G0477 — under most circumstances.

Reason: “The new code descriptors clearly indicate that the new HCPCS codes [G0477-G0483] include specimen validity testing,” explains Hammer. These edits have a modifier indicator of 1, meaning you might be able to report them together in certain situations.

Also: “Medicare added bundling edits to prevent payment for more than one presumptive drug test per date of service,” says Hammer.

In other words:

• G0477 is bundled into 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., dip sticks, cups, cards, cartridges], includes sample validation when performed, per date of service) and G0479, and
• G0478 is bundled into 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).

These bundling edits have a modifier indicator of 0, meaning you can never unbundle them with a modifier.

Analysis: This edit was inevitable, considering the code descriptors that were on the books. It was only a matter of time before CCI squared its rules with “what the CCI Manual has stated since 2015, as well as matching the ‘validity testing’ inclusion in the new [drug assay CPT®] code descriptors,” Hammer says.