Pathology/Lab Coding Alert

Don't let proposed CPT and 'G' codes confuse you.

With two new codes proposed for urine drug testing in 2011 -- hot on the heels of new drug codes and mid-year policy changes in 2010 -- you might need some help sorting it all out. Read on to get a preview of the 2011 codes and a rundown of how current policy meshes with your lab's drug screen test method.

2011 Codes Close Loopholes

At its annual clinical laboratory public meeting on July 22, CMS provided a sneak peak at new lab test codes for CY 2011. You'll need to be familiar with the following two new codes for drug testing next year (X represents unassigned digits in these preliminary code numbers.):

• 801XX -- Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure
• GXXX1 -- Drug screen, other than chromatographic; any number of drug classes, per specimen.

With identical definitions, new code 801XX will replace G0430 (Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure), which was new in 2010.

Problem: "Apparently CMS intends new code GXXX1 to close a loophole in how labs use another code introduced in 2010 ��" G0431 (Drug screen, qualitative; single drug class method [e.g., immunoassay, enzyme assay], each drug class)," says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

"What happened in response to G0431 is that many labs switched to manufacturers' drug screen kits that use a single analyte strip or paddle for each drug class -- dipped in a single urine specimen," Dettwyler explains. "This allowed labs to code each drug class as a single unit of G0431."

Loophole closed: By making the unit of service the "specimen" for GXXX1, labs can only list multiple units if the patient provides multiple urine specimens. "The 'per specimen' wording should materially prevent labs from billing GXXX1 for each drug class dipstick as they could for G0431," Dettwyler says.

Stop future 'gaming': Questioning similar drug screen coding loopholes based on lab method, James Slattery, CEO of Millennium Laboratories in San Diego asked at the July 22 CMS meeting, "is it right that a cup gets $20 while 10 strips get $200 and a cartridge gets ... 10 times that?"

"We are advocating for a higher, though moderate, reimbursement level ... for performing drug screening tests," Slattery said ��" regardless of technology. Such payment would allow providers to  stop trying to "get around the rules" and choose a test method that won't make them lose money, he said.

Another option: "What CMS should have done is add new codes that would cover the cost of performing ranges of drugs, such as a code for two to five classes and a code for six or more drug classes," Dettwyler suggests. "The codes CMS proposes won't solve the problem."

Note: CMS placed G0430 and G0431 on the list for pricing "reconsideration request" at the July 22 meeting. Stay tuned to see how this might play into the reimbursement picture for urine drug testing in 2011.

Follow Current Drug Screen Rules

Until new codes take effect in 2011, you'll need to continue to report drug screening tests using G0430 and G0431, as well as the following codes:

• 80100 -- Drug screen, qualitative; multiple drug classes chromatographic method, each procedure
• 80101 -- ... single drug class method (e.g., immunoassay, enzyme assay), each drug class.

CMS created the two G codes in 2010 "to operate in place of and alongside existing CPT code 80100 and 80101" because "some providers were incorrectly using" those codes, according to CMS.

Do this: Follow these coding rules for Medicare and other payers until 2001:

G0431 and G0431-QW (CLIA waived test) replace 80101 and 80101-QW entirely for Medicare beneficiaries as of April 1, 2010, says Larry Small, M.S., MT (ASCP), lab compliance and billing consultant with Colaborate in Tampa, Fla. Continue to use 80101 for non-Medicare patients.

For qualitative drug screening tests for multiple drug classes using chromatographic methods, report 80100 for Medicare and other payers.

For a qualitative drug screening test for multiple drug classes that does not use chromatographic methods, report G0430 or G0430-QW for Medicare beneficiaries, depending on the lab's CLIA certification. Limit G0430 to one unit per procedure.

Resource: You can find the CMS instructions for these codes, effective since April 1, 2010, in Change Request 6852 at www.cms.hhs.gov/Transmittals/downloads/R653OTN.pdf.

Heads Up for 2011 Coverage Changes

"Once 801XX is active, watch for CMS instruction to drop G0430 and G0430-QW," Dettwyler says.

Less certain is the fate of G0431. "Although GXXX1 will probably replace G0431 for multiple drug class test kits, it's not clear if G0431 will remain active for individual drug class tests run on chemistry analyzers," Dettwyler says.

Also unclear is whether 801XX will replace 80101 so that labs will have to bundle multiple drug class tests into one code, similar to current practice for lab test panels run on chemistry analyzers.

Resource: You can see the new 2011 lab codes at www.cms.gov/ClinicalLabFeeSched/Downloads/CY2011-Public-Meeting-New-Test-Codes.pdf.