Pain Management Coding Alert

Here’s your scoop on new code choices from CPT® and HCPCS. 

Drug test codes undergo many changes in 2015, no matter which type of screening you report. Read on for details on updates to presumptive drug screenings that your pain management specialist might conduct and how you should report the service. 

The basics: Drug procedures are divided into three subsections: therapeutic drug assay, drug assay, and chemistry. Provider use therapeutic drug assays to monitor clinical response to a known, prescribed medication. The two categories of drug assays – which often apply to pain management patients – are presumptive and definitive drug classes. 

• Presumptive Drug Class procedures identify possible use or non-use of a drug or drug class. A presumptive test may be followed by a definitive test in order to specifically identify drugs or metabolites 
• Definitive Drug Class procedures are qualitative or quantitative tests to identify possible use or non-use of a drug. These tests identify specific drugs and associated metabolites, if performed. A presumptive test is not required before a definitive test. 

Remember that the term “presumptive” is often considered interchangeable with the term “qualitative” – a drug screen that providers use to detect the possible, but not definitive, presence of a particular drug in the body. Providers can use either blood, saliva, or urine samples for these tests, but urine is the best specimen for broad qualitative screening since blood is relatively insensitive for many common drugs (such as psychotropic agents, opioids, and stimulants).

Payer explanation: According to the Palmetto LCD (local coverage determination), “Urine or oral fluid is the preferred biologic specimen for testing because of the ease of collection, storage, and cost-effectiveness.  Detection time of a substance in urine is typically 1-3 days depending on the drug, rate of metabolism, and rate of excretion.”

Get to Know the New Code Options

CPT® 2015 deletes all drug screening codes in the range 80100-80104. Instead, you should turn to a new set of codes for presumptive drug screening: 

• 80300 – Drug screen, any number of drug classes from Drug Class List A; any number of non- TLC devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation including instrumented-assisted when performed (e.g., 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 (e.g., 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 (e.g., ELISA) or non-TLC chromatography without mass spectrometry (e.g., 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) (e.g., 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 (e.g., TOF, MALDI, LDTD, DESI, DART), each procedure.

Important notes: As always, you should pay close attention to the descriptors to help you choose the best one for the situation. With these five new codes, take special note of whether they apply to Drug Class List A or List B; whether they are for a single drug class or any number of drug classes; and whether you report the code based on the date of service or the number of procedures completed. 

You’ll find Lists A and B in the CPT® 2015 introductory guidelines for these codes. When a test is referred to as “simpler method,” it includes any test that is not thin layer chromatography, such as immunoassay, that the analyst can read by direct optical observation, including dipsticks, cups, cards, and cartridges. This method may involve the use of an instrument such as a desk top analyzer. 

Don’t Overlook HCPCS Test Codes

For 2015, the HCPCS code set continues to include the two following coding options for drug screenings: 

• G0431 – Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter
• G0434 – Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter. 

Special criteria apply to when you can report each of the codes. For example, you can only report G0431 if the drug screen test is classified as a CLIA high complexity test. Other guidelines pertaining to G0431 include: 

• Only labs with CLIA high complexity certification can perform these tests. 
• You can only report G0431 once per patient encounter. 
• You should not append modifier QW (CLIA waived test) to the claim line. 
• Code G0431 has a maximum of one unit of service and maximum of one line item on the claim.

A different list of criteria applies to G0434:

• The code includes qualitative drug screen tests that are waived under CLIA, as well as tests that are classified as moderate complexity. 
• Labs with a CLIA certificate of waiver may only perform tests classified by the FDA as waived tests. 
• You can report a maximum of one unit of service and one line item of G0434 on the claim for a single patient encounter. 

Providers sometimes decide to repeat a lab test on the same day to obtain subsequent (multiple) test results. Under many circumstances, you can identify the second lab test by reporting its usual CPT® code and appending modifier 91 (Repeat clinical diagnostic laboratory test). You can’t automatically include modifier 91 for all scenarios, however. Keep these guidelines in mind: 

• Do not report modifier 91 when the provider reruns tests to confirm the initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. 
• Do not report modifier 91 when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). 
• Do not use modifier 91 to bypass MUE limit and report multiple line items of G0431 or G0434.