Pathology/Lab Coding Alert

‘Pay more,’ stakeholders say.

Definitive drug test codes G0480-G0483 were on the docket for payment “reconsideration requests” at the Clinical Laboratory Fee Schedule (CLFS) Annual Laboratory Public Meeting held July 18, 2016.

If your lab has been struggling with covering the costs of the following tests, relief may be on the way:

• G0480 — 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, 1-7 drug class(es), including metabolite(s) if performed
• G0481 — … qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed
• G0482 — … qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed
• G0483 — … qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class (es), including metabolite(s) if performed.

Commentators Indict 2016 Pricing, Ask for More

Following almost universal dissatisfaction with the definitive (confirmatory) drug code payment rate for 2016, CMS agreed to hear comments and reconsider the CLFS payment rate for these codes for 2017.

“Final payment rates set by CMS for definitive drug testing are significantly below the cost to perform the tests,” said Lance Benedict, MD representing National Independent Laboratory Association at the public meeting. “The [2016] rates set by CMS represent cuts exceeding 50 percent from 2015.”

Agreed: The “drastically low” payment levels established for these tests last year are “stifling research and development, innovation, and improvements necessary to provide clinically useful and valid results to practitioners,” according to Kristian Foy, representing the California Clinical Laboratory Association at the meeting.

CMS had set the 2016 rates according to the following calculations:

• G0480 crosswalk to 2 x 82542 + 5 x ¼ of 82542 ($79.94 NLA)
• G0481 crosswalk to 2 x 82542 + 12 x ¼ of 82542 ($122.99 NLA)
• G0482 crosswalk to 2 x 82542 + 19 x ¼ of 82542 ($166.03 NLA)
• G0483 crosswalk to 2 x 82542 + 27 x ¼ of 82542 ($215.23 NLA)

Recommendations: Multiple presenters at the recent public meeting suggested the following payment calculation and rates instead:

• G0480 crosswalk to 6 x 82542 ($147.60 NLA)
• G0481 crosswalk to 8 x 82542 8($196.80 NLA)
• G0482 crosswalk to 10 x 82542 ($246.00 NLA)
• G0483 crosswalk to 12 x 82542 ($295.23 NLA)

Timeline: After considering comments at the public meeting, CMS will post their preliminary payment recommendations as soon as possible, hopefully around the first of September, according to CMS’s Glenn McGuirk, speaking at the event. You’ll also have an opportunity for public comment at that time. You can access the proposed codes now, and the basis of payment when available, at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Laboratory_Public_Meetings.html.