Steer clear of the 80100 series for this payer.
If you’re reporting drug screening tests for Medicare beneficiaries, you won’t be able to report the standard drug screen codes from your coding manual. That’s because Medicare won’t accept CPT® drug screen codes 80100, 80101, or 80104.
Turn to HCPCS Level II for Medicare
Instead, you’ll need to report one of the following codes if a physician orders a drug screen for a Medicare beneficiary:
You can see that CMS has established a two-tier drug-screen coding system that doesn’t align with the distinctions you’d make if you’re reporting CPT® drug test codes.
Know CLIA Certification
The key to selecting the proper HCPCS Level II drug screening code is understanding how the Clinical Laboratory Improvement Amendments (CLIA) categorizes tests into three complexity groups, as follows:
You should choose between G0431 and G0434 based on the CLIA complexity classification of the specific lab test you’re using.
Do this: Divide your Medicare drug screen coding as follows:
Beware of These Compliance Issues
Bundling issues, units of service, and modifiers require your attention when you’re billing Medicare for drug screening tests.
Watch units: You should report only one unit of G0431 or G0434 per patient encounter, regardless of the number of drug classes you detect. You might have circumstances that require more than one medically necessary drug screen for the same patient on a given day, although CMS expects such instances to be rare.
Check edit pairs: The Correct Coding Initiative (CCI) bundles G0434 as a column 2 code for G0431. You cannot bill these codes together under any circumstances. That means you’ll need to select the most extensive procedure code — G0431 — if labs perform both complex and lower complexity drug screens on the same day.
Use modifier: If your lab operates with a certificate of waiver, you may perform only waived-status tests that code to G0434. When you do so, you’ll need to append modifier QW (CLIA waived test).
Laboratories with a CLIA certificate of compliance or accreditation should not append the QW modifier to claim lines, even if they perform a CLIA waived test.
Resource: To see what CMS has to say about drug screen coding, go to www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1105.pdf