OIG and CMS Are Both Watching Drug Specimen Validity Testing … Are You?

Coding for drug testing and specimen validity testing was the focus of recently released MLN Matters SE18001. At the end of the MLN article, there’s a link to an OIG report on the topic revealing millions in improper payments.

If CMS and the OIG consider something you code worthy of focus, you really should read up to be sure you understand the policy. And while you’re reading, keep in mind the larger tangle of Correct Coding Initiative (CCI) rules for drug testing codes, including proprietary lab analyses (PLA) codes, to grasp the full picture. Here are some pointers to keep in mind.

Understand the Coding Structure

The MLN article explains that for testing for drugs of abuse, the coding structure divides codes based on screening (aka presumptive) and quantitative/definitive testing.

Pick One Presumptive Drug Testing Code

The codes for presumptive drug testing that Medicare accepts are 80305-80307. The methodology’s complexity is what differentiates the codes. You may report only one code from 80305-80307 per date of service, the MLN article states.

Apply This PLA Bonus Tip

MLN SE18001 doesn’t discuss this, but there are PLA codes like 0007U that involve presumptive drug tests. Code 0007U also includes definitive confirmation of positive results. When you check the CCI edits for 0007U, you’ll find 80305-80307 bundled in with a modifier indicator of 0, meaning you may never override the edit. Definitive drug test codes G0480-G0483 and G0659 are also bundled with 0007U with modifier indicator 0. Read about those definitive codes next.

More About Those Definitive Drug Tests …

SE18001 directs you to CCI manual, chapter 10, section E, for information on using G0480-G0483 for definitive drug testing. Like the presumptive codes, you should report only one code from the definitive range per date of service. The MLN Matters article goes on to add that labs performing a less sophisticated test may find G0659 to be the appropriate code.

Here’s the All-Important Validity Testing Rule

Do not separately bill validity testing when you perform it on urine specimens used for drug testing. The article states, “For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed.”

The MLN article doesn’t provide a specific code example for validity testing, but the work described by urinalysis code 81003 is an example of what a provider might use (and incorrectly report) as a validity test.

Know the Numbers From the OIG Report

The OIG report mentioned in the intro found $66.3 million in improper payments for validity testing during 2014-2016. (The CMS response was that further medical review would be needed to check true medical necessity in each case.)

CMS implemented a system edit to prevent improper payments April 1, 2016, but in the nine months after that, OIG still found that Medicare made $1.8 million in improper payments.

How? Some providers had used modifiers to override the edit inappropriately. Diagnosis codes did not support medical necessity for reporting both codes.

In response to OIG recommendations, CMS is looking at adding additional system edits and providing education to providers, so stay alert.

What About You?

Are you surprised the issue of validity testing is a concern? Or do you think the rules need to be changed to be less confusing?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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