Pathology/Lab Coding Alert

Coverage Policy:

Focus on 7 New Drug Test 'G' Codes for Medicare

Published on Fri Jan 08, 2016

See how the change impacts your bottom line.

Labs had to wait in suspense almost to the end of 2015 before CMS released the “final” (with 60 day comment period) codes and pricing for drug testing in 2016.

Now you need to know which HCPCS Level II codes Medicare deletes — and adds — as well as which CPT^® codes Medicare won’t recognize.

Let our experts point the way to make sure you correctly code your drug screening and confirmation testing to Medicare in 2016.

Delete These Codes

In 2016, you won’t be using the following, since CMS deletes these three codes:

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
G6058 — Drug confirmation, each procedure

You should also stop using the codes that Medicare instituted in 2015 to capture definitive drug testing for specific drugs and drug classes (G6030-G6058).

Removing G6030-G6058 should come as a huge relief to labs. Recall that these codes reflected CPT^® 2014 codes, many of which had been deleted or modified in 2015. That meant last year’s CMS solution was “not that simple to implement,” recalls Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, internal audit manager at PeaceHealth in Vancouver, Wash.

Ignore These Codes

After a year of experience with about 100 new CPT^® 2015 codes for drug test reporting, Medicare still says “no” to these codes. The agency had initially indicated its intention to consider these codes for 2016, once they’d had time to evaluate the payment impact.

Avoid: For Medicare beneficiaries, you should not use the following codes in 2016, just as you didn’t in 2015:

80300-80304 — Presumptive drug class list A and B
80320-80377 — Definitive drug class testing, per drug class

That’s not all: “More and more private payers also declined to use these CPT^® codes in 2015, and instructed labs to bill their drug code testing using the HCPCS Level II “G” codes that Medicare instituted,” says William Dettwyler, MT AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. “And I anticipate that we’ll see even more payers moving to the new “G” codes that Medicare institutes for 2016.”

Use These Codes

For 2016, CMS puts in place the following codes to report presumptive drug testing:

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., dipsticks, cups, cards, cartridges), including sample validation when performed, per date of service
G0478 — … any number of devices or procedures (e.g. Immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), including sample validation when performed, per date of service
G0479 — … any number of devices or procedures by instrumented chemistry analyzers (e.g. immunoassay, enzyme assay, TOV, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service

Recall: Presumptive drug tests, also called screening, check for the presence of drug classes, but don’t identify/distinguish specific drugs.

“You should bill just one presumptive code per day for a single patient,” Dettwyler says. “Even if you perform the drug screen tests on a chemistry analyzer, no matter the number, or the CLIA complexity, you should not report more than one unit of G0479 per date of service.”

Pricing: Here’s what you can expect for payment for these tests in 2016, relative to what your lab got paid in 2015

G0477 crosswalk to 0.75 times G0434 ($14.86 national limit amount)
G0478 crosswalk to G0434 ($19.81 NLA)
G0479 crosswalk to 4 times G0434 ($79.25 NLA)

For definitive drug testing in 2016, Medicare institutes the following codes:

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

Remember: Definitive drug testing, also called confirmatory testing, identifies and/or quantifies specific drugs and possibly metabolites in a listed class.

“You should bill a specific drug class just once per day under these codes,” Dettwler says. Although you should not bill the CPT^® codes to Medicare, the drug classes for billing G codes are consistent with CPT^® manual.

Bottom line: Here’s how you can expect the new codes to impact your pay for 2016: