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New 2016 drug testing codes impacting payor payment policies



May 05, 2016
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement 

As part of the Calendar Year 2016 Clinical Laboratory Fee Schedule (CLFS) Final Determinations issued by the Centers for Medicare and Medicaid Services (CMS), drug testing codes G6030-G6058 were eliminated and replaced with new HCPCS “G” codes, which now differentiate between presumptive (used to identify possible use or non-use of a drug or drug class) drug testing and definitive (qualitative or quantitative methods that identify possible drug use or non-use and identify the specific drugs and associated metabolites) drug testing.

The following three new HCPCS “G” codes have been created for presumptive testing; only one of these codes may be billed per day.

Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service

Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.


Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service.


The following four new HCPCS “G” codes have been created for definitive testing; only one of these codes may be billed per day.



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 (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed.



G0481



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 (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed.



G0482



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 (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed.)



G0483



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 (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed.



Medicare also continues its non-recognition of CPT codes (80300-80377) for drug testing. Recently, a number of commercial health plans, including Aetna, Anthem Blue Cross and Health Net, have changed their reimbursement policies to be reflective of Medicare's policies. Other commercial payors continue to review the CMS policy changes to determine if any modifications of their payment policies are warranted.

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