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2016 Replacement Codes for G0431 and G0434


Current coding for testing for drugs of abuse relies on a structure of “screening” (known as “presumptive” testing) followed by “confirmation” to confirm the results of the screening tests and quantitative or “definitive” testing that identifies the specific drug and quantity in the patient.

Presumptive Testing

A test used to detect the presence of a drug in a urine sample. The test is performed by a provider with Certification of Waiver or a Medical Test Site Accredited License. Findings are reported qualitatively as either positive or negative.

Definitive Testing

Definitive tests are performed in a laboratory or by a provider with Certificate of Registration, Compliance of Accreditation or Medical Test Site Categorized License or Accredited License.  The tests are able to quantify the amount of drug or metabolite present in the urine sample. definitive tests can be used to confirm the presence of a specific drug identified by a screening test and can identify drugs that cannot be isolated by currently available presumptive testing. Results are reported as specific levels of substances detected in the urine sample.

Effective for the dates of services from January 01, 2016 CMS implemented the following changes for drug testing;

1. Deleted the HCPCS codes G0431, G0434 and G6030 through G6058

2. Continue to not recognize the AMA CPT codes 80300 – 80377

3. For presumptive testing, created three G codes: 

G0477 - Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 

G0478 - Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service

G0479 - Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service

4. For definitive drug testing, created four tiered G codes:

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

Guidelines to report Presumptive Testing;

Presumptive codes G0477 - G0479 is eligible for reimbursement when testing is performed in an office, laboratory or facility setting.  These codes are not eligible for reimbursement for chemical dependency facilities. Reimbursement for procedure codes G0477 - G0479 is limited to one unit per day. Only one of the three codes may be billed per day.

Guidelines to report Definitive Testing;

The definitive tests must be both more sensitive and specific than the initial screen. Reimbursement for procedure codes G0480 - G0483 is limited to one unit per day. The unit used to determine the appropriate code to bill is "drug class."  The number of drug classes tested determines the appropriate code to use.  Each drug class may only be used once per day. Only one of the four codes may be billed per day.

Modifiers

Modifiers 59, XE, XP, XS, XU and 91 should not be reported with procedure codes G0477-G0479 and G0480-G0483 to bypass the edits.

Reference:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2016-CLFS-Codes-Final-Determinations.pdf

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