Knowledge Base Article

Q:

Recent National Correct Coding Initiative (NCCI) procedure-to-procedure edits effective April 1, 2016 list the CPT codes for urinalysis (81000, 81001, 81002, 81003 and 81005) as column two codes with the new HCPCS codes for drug testing (G0477-G0483) column one codes. What is the reason for these edits and when is it appropriate to by-pass these edits with a modifier?

A:

All of the new drug testing HCPCS codes for 2016 (G0477-G0483) include “sample validation when performed” in the code description. Sample validation is testing to confirm the specimen has not been tampered with. Various urinalysis tests, such as specific gravity which is part of a routine urinalysis and urine creatinine for example, are common tests that are used for sample validation. Although CMS does not give a reason for all CCI edits, it is likely this is the reason for these edits.

Providers will need to check the physician’s order to see if the urinalysis was done for sample validation or for medically necessary reasons related to the patient’s condition. If there was a medical need for the urinalysis, it is appropriate to add a 59 modifier (separate and distinct service) to by-pass the CCI edits. The modifier is to be appended to the column two code, in this case, the urinalysis codes. If the testing is for sample validation (also known as specimen integrity) then you should not bill the 8100x code separately.