Pathology/Lab Coding Alert

You have two new HCPCS 2010 codes for Medicare beneficiary drug screens, but do you know how to use them? No sooner did CMS roll out the codes than the agency instituted some restrictions. Round up all the facts you need so you can pick the right code with just three expert tips.

If you're reporting drug screen testing for non-Medicare payers, your code choices remain the same as they have been for years:

• 80100 -- Drug screen, qualitative; multiple drug classes chromatographic method, each procedure

• 80101 -- Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class.

For Medicare patients, HCPCS 2010 introduces two new codes that you'll need to keep in mind:

• G0430 -- Drug screen, qualitative; multiple drug classes other than chromatographicmethod, each procedure

• G0431 -- Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class.

Do these codes replace 80100 and 80101? Not completely -- not yet, anyway. According to CMS instruction in MLN Matters number SE1001, the two new G codes operate "in place of and alongside existing CPT code[s]" 80100 and 80101.

Know when to substitute: The G0431 and 80101 definitions are identical, and MLN Matters states, "new test code G0431 is a direct replacement for 80101." But G0431 is not a direct replacement yet -- not for all labs, according to CMS. Read the next tip to learn why.

Until April 1, labs should choose G0431 or 80101-QW (CLIA waived test) based on whether the lab operates under a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver.

Here's why: CMS is delaying full G0431 implementation until April 1, according to MLN Matters. Until that time, CMS instructs labs to report qualitative drug screening tests for a single class of drugs -- regardless of testing methodology -- as follows:

• CLIA waived labs -- continue to bill 80101-QW

• All other CLIA certification levels -- report G0431.

Medicare has promised further instruction by March 31. "Probably, G0431 will replace 80101 and 80101-QW entirely for Medicare beneficiaries at that time," says Larry Small, M.S., MT (ASCP), lab compliance and billing consultant with Colaborate in Tampa, Fla.

Lab method is the crucial distinction between 80100 and G0430.

Problem: CMS points out that "80100 describes only chromatographic testing for the presence of drugs, which [leaves] certain laboratories unable to bill accurately" when performing a qualitative multiple drug class screen that doesn't use chromatography, according to MLN Matters number SE1001.

Solution: CMS implements G0430 "to remove the limitation of method (chromatographic)" when the lab uses a non-chromatographic method for a qualitative multiple drug class screen, states  MLN Matters.

From Jan. 1 through March 31, you should use the codes in the following manner, according to MLN Matters:

• Report 80100 when performing qualitative drug screening test for multiple drug classes using chromatographic methods

• Report G0430 when the qualitative drug screen test for multiple drug classes does not involve chromatography. "I rarely if ever apply 80100 to screening procedures that would be billed to Medicare," Zweifel says. Industrial accounts or medical/legal screenings more often use the chromatographic drug tests, she says.

Limit units: CMS created G0430 not only to provide a non-chromatographic option, but also to "limit the billing to one time per procedure," according to MLN Matters. Several kits/cartridges have come to market in recent years that detect the presence of multiple drug classes, according to Zweifel. When the lab uses one of these methods involving a single, non-chromatographic procedure, you should report a single unit of G0430.

Tip: To properly code a qualitative drug screen, you'll need to review the package insert to confirm the methodology, Zweifel advises.

Old codes allowed erroneous billing: Existing codes 80100 and 80101 created a coding dilemma. If a lab performed a single procedure to identify multiple drug classes, but the method was not chromatography, labs couldn't use 80100 (which specifies chromatography.) As a result, some labs reported these tests as 80101 x the number of drug classes, even though the test didn't identify each drug class separately. Kits that screen for 10 drug classes in a single procedure could mean the lab takes in nearly $200 (based on clinical laboratory fee schedule national amount for 80101 of $19.72).

CMS corrects coding: By providing G0430, which doesn't specify chromatography, labs have an accurate code to describe single-procedure multiple-drug class kits by other methods.

Remember to watch for further CMS instruction for using G0430 versus 80100 starting April 1.

Resource: To read the entire MLN Matters number SE1001, go to www.cms.hhs.gov/MLNMattersArticles/downloads/SE1001.pdf