Drug screening codes have changed

There are now two drug screening codes for reporting use of a multiplexed screening kit that tests for multiple drugs or drug classes. The Centers for Medicare & Medicaid Service published new HCPCS code G0434 for the multiplexed drug screening to differentiate these tests from those that are more complex. CPT followed with new code 80104 for the same purpose. The descriptors for these new codes follow:

• 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 if you have CLIA certificate of waiver)"

• 80104, "Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure"

Use the G code for Medicare claims, and use the CPT code for other claims. The Medicare Clinical Laboratory Fee Schedule shows an average fee of $20.67.

CMS explained in MLN Matters publication SE1105 (PDF download) that refining the drug screen testing codes and revising the descriptors was done to avoid unnecessary or excessive utilization of code G0431 for relatively simple point-of-care tests that screen for multiple substances. In addition to introducing code G0434, code G0431 was changed from “Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class” to “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.” If your practice has received denials for claims with dates of service on or after Jan. 1, 2011, that use code G0431QW for tests conducted with the kits listed in MLN Matters publication MM7266 (PDF download), corrected claims should be submitted with code G0434QW. For dates of service on or after April 1, 2011, claims that use code G0431QW will be denied. 

Also effective Jan. 1, 2011, code G0430 has been deleted and replaced with code G0434. Therefore, the code G0434QW replaces G0430QW. 

G0434 should be used to report very simple testing methods, such as dipsticks, cups, cassettes and cards, that are interpreted visually or with the assistance of a scanner, or that are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code should also be used to report any other type of drug screen testing using test(s) that are classified as Clinical Laboratory Improvement Amendments (CLIA) moderate complexity test(s), keeping the following points in mind:

• G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc., that are not CLIA-waived.

• Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver should bill using the QW modifier.

• Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation should not append the QW modifier to claim lines.

• Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines.

Note that the "per encounter" reporting for G0434 doesn't prevent reporting when a patient is tested in two different settings, such as when a patient tested in the physician's office in the morning later reports to the emergency department and receives a second test.

The MLN Matters publication mentioned earlier (MM7266) also provides a listing of the drug kits that should be reported using the new code G0434 with the QW modifier to signify the test's waived status. Each quarter CMS publishes a list of all test products with CLIA-waived status. Providers may use this list to determine if a particular test product can be appropriately performed by a laboratory with a CLIA waiver and is eligible to be billed using the QW modifier. However, the currently displayed list is from Jan. 5, 2010. You can view the most recent list as provided to the Medicare contractors in Medicare CR7266 (PDF download).

If you are unsure about Medicare coverage of drug screening tests, this information is available from the Medicare Coverage Database and the Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report dated January 2011. I found local coverage determinations for qualitative drug screens posted by National Governments Services Inc., First Coast Service Options Inc., and Palmetto GBA by searching the term "drug screen" in the Medicare coverage database. 

I may have just set the record for the most links in a Getting Paid blog, but I'm sure my drug screen would come out clean. I just like to provide the sources for further information and to help you and your staff keep up with these ever-changing codes and coverage decisions.