Wiki Drug Screens 80307, G0481

[Leondra]

Hello,

We are a Pain Management clinic and we have our on in house lab. About a week ago we started having issues with our drug screens we bill 80307 and G0481. Ins is paying for the 80307 and not G0481. We have always been paid on both codes. Has anyone else had this issue?

MEDICARE RAILROAD
CO-236 This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/fee schedule requirements

MEDICARE
CO-236 This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/fee schedule requirements

TRICARE
CO-A1 Claim /service denied. at least one remark code must be provided( may be comprised of either the NCPDP reject reason code,or remittance advice remark code that is not an ALERT

Per my Tricare conversation this is an unbundled relation per the CCI billing guidelines.

 

[kjdallas]

Look at CMS NCCI edits, as of July 1st they have said they are not payable together. However, they also said that it would change where you can use a modifier to get them both paid, but they have until October 1st to change their software to accept the modifier. I called AAPC and they did not call me back. I also spoke to a representative at Cigna who told me to put a modifier on the G code.

 

[Leondra]

Look at CMS NCCI edits, as of July 1st they have said they are not payable together. However, they also said that it would change where you can use a modifier to get them both paid, but they have until October 1st to change their software to accept the modifier. I called AAPC and they did not call me back. I also spoke to a representative at Cigna who told me to put a modifier on the G code.

Thanks for your response! What modifier are they stating we use? Will you keep me posted on what AAPC says if they return your call?
Leondra~

 

[kjdallas]

AAPC never called me back. SAD!
I spoke to Medicare, but you know they never tell you what or how to code...I did have a billing software company tell me to put a 59 modifier on the G code. I have noticed on our EOBs that Aetna is paying the G code and not paying the 80307.

 

[lacey2324]

I am experiencing the same issues, however, when I billed out the G code with modifier 59, Medicare rejected our claim.
Any other suggestions that might work?

 

[Leondra]

AAPC never called me back. SAD!
I spoke to Medicare, but you know they never tell you what or how to code...I did have a billing software company tell me to put a 59 modifier on the G code. I have noticed on our EOBs that Aetna is paying the G code and not paying the 80307.

That's very sad!
Exactly, they like to make us hunt for everything. That's what I've been doing as well using the 59 Modifier on our G codes. Some payors have paid both codes with the modifier and some are still denying the claims per our payment poster. The ones that are paying they are only the 80307 and not the G codes even with the modifier 59 it's so frustrating. We have our payment poster appealing them until the Medicare edits take place in Oct. Hopefully, once that is updated ALL payors will pay both code with modifier attached. Thanks for responding back! Please, keep me updated once you start seeing payments coming in on both code please. Have a great day!!!

 

[Leondra]

I am experiencing the same issues, however, when I billed out the G code with modifier 59, Medicare rejected our claim.
Any other suggestions that might work?

Unfortunally, you will have to try and appeal those as we are doing in our office or wait until the Medicare updates their NCCI edits in Oct.


Effective July 1, 2023, CMS implemented NCCI PTP edits between Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480 – G0483, and G0659 for definitive test(s). Currently, these edits cannot be bypassed using an NCCI modifier; however, CMS will change these edits to a CCMI of 1, which will allow for the use of a modifier to bypass the edits in those circumstances when billing these codes together is allowable. These circumstances are generally defined by the Medicare Administrative Contractors (MACs) in Local Coverage Determinations. This change to allow the use of a modifier will be retroactive to July 1, 2023; the Medicare claims processing systems will implement this change in the next quarterly update effective on October 1, 2023. In the meantime, if laboratories bill the MACs for these tests together on or after July 1, 2023, and believe that an NCCI modifier is appropriate, the lab should include the applicable modifier on the claim. The MACs will adjust those claims with dates of service between July 1, 2023 and October 1, 2023 to allow payment when an NCCI modifier was used. Alternatively, a laboratory may also choose to use the MAC appeals process if it does not wish to wait for the automatic adjustment to occur, or it can wait to submit its claims until CMS implements the change.