Documenting time for preventive services
We are being told that we must document time separately for Medicare preventive services that include time in the code descriptor when these services are provided in conjunction with an annual wellness visit or evaluation and management service. Is this correct?
Yes. There is nothing in the Medicare guidance that exempts these services from the requirement to document start and stop times or total time spent providing the individual service. It is important to note that although several services include “15 minutes” in their descriptor to indicate a minimum time threshold for reporting, the National Coverage Determinations Manual indicates that the Centers for Medicare & Medicaid Services will cover annual screening for depression up to 15 minutes for Medicare beneficiaries when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up. In other words, time must be documented, but 1 minute to 15 minutes are covered in this case. Be sure to also use the “5 As” approach (assess, advise, agree, assist, and arrange) to document services that require counseling. An example would be behavioral counseling for alcohol misuse, which would need to include evidence that the counseling was consistent with the 5 As approach.
Drug screening in the office
What are the appropriate codes to report for drug screening performed in our office to rule out illicit drug use, confirm appropriate use of prescribed pain medications, or comply with state guidelines for prescription of controlled pain medications?
Code 80300 is typically appropriate for reporting in-office screening for presence of drugs (qualitative screening), such as screening for compliant use of prescription drugs. However, there are exceptions for patients with Medicare and payers that follow Medicare policy on drug screening. Because of concerns about potential overpayment, Medicare does not recognize CPT codes for drug screens and assays and has created HCPCS G codes for this. Some Medicare contractors have also adopted a local coverage determination limiting coverage of drug screening. For example, coverage might be limited to management of a patient with chronic pain in which there is a significant pretest probability of non-adherence to the prescribed drug regimen as documented in the patient's medical record. You should verify coverage in your area before providing these services. The table below includes the CPT and HCPCS codes for screening with tests that use direct optical observation (e.g., dipstick or cup) or multichannel chemistry analyzers that use immunoassay or enzyme assay.
| Current Procedural Terminology (CPT) |
| 80300 Drug screen, any number of drug classes from Drug Class List A*; any number of non-TLC devices or procedures (e.g., immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (e.g., dipsticks, cups, cards, or cartridges), per date of service. |
| 80301 Drug screen, any number of drug classes from Drug Class List A*; single drug class method, by instrumented test systems (e.g., discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service. |
| Healthcare Common Procedure Coding System (HCPCS) |
| G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter. (Add modifier QW for waived test.) |
*See your CPT reference for Class List A drugs and for Class List B drugs and codes. Testing for Class List B drugs typically requires more work (e.g., sample preparation).
