Wiki 80104 Billing Help Needed

[DenaBradford09@yahoo.com]

I currently work for a Dr. who does a high complexity drug screen and he has a high complexity lab. Therefore he bills procedure code 80104 for his drug screens obtained in his office.

80104, "drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure". This code is used for reporting use of a multiplexed screening kit that test for multiple drugs or drug classes.

They provide a positive or negative result rather than specific measurements of the level of a drug or drugs. The methods of collecting / testing include, but not limited to: cassettes, cubes, cups, dip cards, strips, and swabs. A procedure is defined as a single device or separate set of regents, using an instrument, to produce one or more test results. It should pay 16.64 per unit billed.

This code has been billed with Insurance co's such as: BCBS, Aetna, Cigna, and UHC.

We have now been told by BCBS, Aetna, Cigna to bill with Code G0431, which is a drug screen, qualitative; multiple drug classes by high complexity test method. This was suppose to only be billed to Mediare, and Medicare Replacements.

Finally my question: Is there anyone that has a better insight on billing with this code, or any knowledge that would help me out with billing it. I need to add we are not CLIA Waved.

 

[marvelh]

Valid HCPCS codes are not for exclusive use of Medicare and Medicare Advantage plans. Many of the commercial payers are shifting to requiring providers to report with the HCPCS G0431 or G0434 code rather than the CPT 80101 or 80104 codes.

If the test method is high complexity and your lab is CLIA credentialed as high complexity, then it would not be appropriate to append modifier QW to the code, instead you would report the diagnostic testing with one unit & one line item of G0431.

 

[clairet001]

We are doing the same high complexity testing from what I see here. We bill G0431-59 x 1 unit for these tests to Medicare, their replacement plans, UnitedHealthcare, and all BCBS plans. The remaining carriers I bill 80101-59 x the number of units of classes tested. Note: our machine is dividing out the sample into separate vials for each class being tested. I imagine the other carriers will follow suit with Medicare soon.