Pain Management: Look to Number of Drug Classes to Determine G0431, G0434 Choice
Steer clear of 80100, 80104 on Medicare claims.
If your pain management specialist conducts urine drug screening (UDS) on Medicare patients, you’ve had some coding changes to put into place for 2011. Questions about correct reporting still abound, so our experts offer top tips to help you understand UDS procedures.
Top tip: “Remember, don’t confuse collecting a urine specimen with performing a UDS test,” says Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co. Most offices will submit 99000 (Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory) when simply collecting the urine specimen in a cup (though 99000 carries a B status indicator in the Medicare Physician Fee Schedule which means the service is bundled or not payable by most insurers). Reporting a UDS test goes beyond 99000.
Focus on Complexity With G Codes
The HCPCS G codes addressing urine drug screenings included an addition, a revision, and a deletion for 2011. The current applicable code choices for Medicare beneficiaries are:
G0431 (revised) -- Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter
G0434 (new) -- Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter.
“It appears that you should choose between these codes based on the CLIA complexity classification of the specific lab test you’re using,” says Robin Miller Zweifel, MT (ASCP), a laboratory coding and billing compliance consultant in Niota, Tenn.
The Clinical Laboratory Improvement Amendments (CLIA) categorizes tests into three complexity groups:
Tests of moderate complexity, including the subcategory of provider-performed microscopy (PPM) procedures
Tests of high complexity.
Only report one unit of G0431 or G0434 per patient encounter, regardless of the number of dipsticks or cups employed during the session.
Watch: The previous descriptor for G0431 applied to a single drug class with no CLIA complexity requirement, but the new revised descriptor applies to multiple drug classes and only those tests that meet the high complexity CLIA classification.
“You can only use one unit now instead of multiple units,” says Dawn Shanahan, CPC, CASCC, CHC, supervisor of coding and assistant compliance officer for Florida Gulf to Bay Anesthesiology Associates in Tampa. “However, the difference in reimbursement could be large, depending on how many drug classes you’re doing. Last year you could get paid per drug class if you were testing for individual drug classes; now you cannot.” If you previously used dipsticks or cups that tested for multiple classes, you won’t see a difference in reimbursement.
Pay day: The Clinical Laboratory Fee Schedule (CLFS) prices G0431 at five times G0434 (national limit amount $102.33 versus $20.47). According to CMS, “By setting the [G0431] payment at a multiple of five …, we are recognizing that multiple drugs are often tested through one specimen and that the high complexity tests that are performed in the laboratory setting require more resources than the simple dipstick test kit tests performed outside the laboratory setting.”
Don’t Slip by Reporting G0430
You might have reported G0430 (Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure) for some drug screen tests in the past, but CMS deleted the code for 2011. The new code G0434 is essentially meant to replace G0430 and should be paid at a similar rate.
CPT® no-no: When CMS deleted G0430 from HCPCS, CPT® added a new code with the same descriptor -- 80104 (Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure). You shouldn’t report 80104 for Medicare patients, however, because CMS states that the 80104 code descriptor “does not accurately reflect the types of tests that need to be captured for accurate billing and payment.” CMS also will not accept another CPT® code for 2011, 80101 (Drug screen, qualitative; single drug class method [e.g., immunoassay, enzyme assay], each drug class). CMS guidelines direct you to submit the edited G0431 code or the new G0434 for Medicare claims instead.
Collections tip: Verify the patient’s insurance before billing for the UDS, Shanahan advises. That way you’ll be certain to report the correct codes, depending on whether the patient has Medicare or other insurance. Also check with your non-Medicare payers to learn whether they want the G codes instead of the CPT® codes for tests.
Understand the Purpose for Pain Management
“The use of prescription opioids has increased over thelast 10 years as an accepted method for treating chronic nonmalignant pain,” Paul J. Christo, M.D., of Johns Hopkins University School of Medicine in Baltimore, Md., writes in the March/April 2011 issue of Pain Physician (“Urine Drug Testing in Chronic Pain”). UDS plays a key role in managing pain patients by monitoring pharmacotherapy compliance, identifying patients who might be at higher risk for drug misuse or relapse, and confirming or documenting the agreed-upon treatment plan.