Knowledge Base Article

America has a drug problem. (Actually more than one considering the rocketing costs of medicinal drugs for patients, payers, and providers, but that would be another article.) Today I am referring to the problem of drug abuse. There is an opioid epidemic fueled by the over-prescribing of pain medications; abuse of illicit drugs continues with newer, cheaper opium derivatives and combinations; and there is also the seemingly never-ending development of new synthetic drugs. Controlling the drug problem in America is a challenge for law enforcement and governmental authorities, but coding for drug testing is a challenge for healthcare providers. The coding challenge is fueled by the also seemingly never-ending changes to drug testing codes from CPT (published and copyrighted by the American Medical Association) and Medicare (HCPCS codes).

Drug testing codes have been changing for many years, but in 2015 CPT did a major overhaul of the drug testing codes. They developed new codes for presumptive drug testing (drug screening) based on testing methods and major groupings of drug classes (Drug Class Lists A and B), and new codes for definitive drug testing based on drug classes and tested by more complex methods. Medicare did not accept the new CPT drug testing code changes for 2015 and instead kept their existing drug screening codes, developed new HCPCS codes for some of the deleted CPT codes, and maintained the previous year’s CPT instructions for selection of other drug testing codes. As a reminder, Medicare’s drug screening codes were based on test complexity and the new HCPCS codes for 2015 were by drug name or class.

The year 2016 saw a complete revision in the HCPCS codes Medicare accepts for drug testing. They deleted all of the HCPCS codes from the previous year (G0431, G0434, and G6030-G6058) and developed a much simpler, straightforward system. The screening or presumptive drug testing codes (G0477-G0479) were based on the testing/reading method and device and the definitive drug testing codes (G0480-G0483) were based on the number of drug classes tested as defined by the CPT drug class definitions. Each new HCPCS code and type of drug testing code (presumptive or definitive) was only to be reported once per date of service and included sample validation testing. There were no drug testing code changes for CPT for 2016.

That brings us to 2017. CPT is changing the presumptive (screening) codes to basically mirror the HCPCS screening codes from 2016 based on testing/reading method and device. They are deleting CPT codes 80301-80304 and replacing them with:

• CPT Code 80305 – drug test(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
• CPT Code 80306 – drug test(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
• CPT Code 80307 – drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service

More simply stated:

• CPT 80305 is drug screening by dipsticks, cups, cards or cartridges read visually
• CPT 80306 is drug screening by dipsticks, cups, cards or cartridges read on an instrument reader
• CPT 80307 is drug screening on a chemistry analyzer
• Each code is only reported once per date of service regardless of the number of drugs tested
• The codes include sample validation testing such as pH, specific gravity, nitrites, etc.

CPT is not making any changes to the definitive drug testing codes (80320-80377) for 2017. These codes are only for complex testing methods that are able to identify individual drugs and distinguish between structural isomers, such as gas or liquid chromatography with mass spectrometry, and specifically EXCLUDE immunoassay and enzymatic testing methods. Each category of a drug class, including metabolite(s) if performed is reported once per date of service. This means each code (or each drug class if described by more than one code) is reported only once a day.

As usual, the Medicare Clinical Lab Fee Schedule (CLFS) Test Codes Final Determinations for the coming year are not available yet, so this discussion for HCPCS codes is based on the Preliminary Determinations (available here). Medicare plans to delete the 2016 HCPCS codes for presumptive testing and go with the above CPT codes for 2017 – not surprising since as stated above, the new CPT codes mirror last year’s HCPCS codes.

Medicare plans to keep their definitive HCPCS codes for 2017 and possibly add one more HCPCS code. Again as stated above, the existing codes (G0480-G0483) are based on the number of drug classes tested as defined by the CPT drug class definitions. And like the CPT definitive testing codes, they are reserved for complex testing methods and exclude testing by immunoassay or enzymatic methods. Medicare is considering increasing the payment rate for these codes for 2017, but remains concerned that “inappropriate testing continues to occur including simplified testing billed at the higher code with suspect results.” Therefore they are proposing a new HCPCS G code (yet to be named) for those labs that are performing a less sophisticated version of these tests than is usually performed in drug testing laboratories that would be paid the same as G0479/80307.

GCCCC: 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), excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase), performed in a single machine run without drug or class specific calibrations; qualitative or quantitative, all sources, includes specimen validity testing, per day.

Another thing for hospitals to remember – the drug testing codes are assigned to Status Indicator “Q4.” This means that if they are performed and reported on the same claim with any other outpatient services, there is no separate payment for the drug testing, for example drug testing during an emergency department visit.

All providers also need to be sure the drug testing is medically necessary, especially related to definitive drug testing of multiple drugs, such as might be ordered from a pain clinic. According to a recent Department of Justice (DOJ) press release concerning a False Claims Act settlement, “The use of quantitative drug tests – tests that are very specific and also very expensive – is appropriate only if there is reason to doubt the more general and cheaper qualitative drug test screens.” There may be times when the treating physician needs to know a specific drug identification – in that case, the medical reason should be clearly documented in the medical record.

Providers need to be on the lookout for Medicare’s final determinations concerning drug testing codes. We will publish those updates in the Wednesday@One when available. Providers may also want to work with their physicians to ensure appropriate documentation to support the medical necessity of drug testing as this continues to be a Medicare concern – see Medicare’s Compliance Fact Sheet for Urine Drug Screening.