HCPCS Codes 2011: G0431, G0434 Include Medicare Drug Screens

CMS scrubs out G0430 and won't pay for 80100, 80101, 80104.

Forget all you considered you knew about reporting drug screen tests to Medicare. With new, revised, and deleted codes for 2011, chances are you won't report your lab's drug testing the same way this year. Read on for an expert HCPCS codes insight.

Questions abound: Fast on the heels of 2010 HCPCS code changes and CMS's surprising 2011 HCPCS codes reversals, many lab coders and billers are puzzled.

Let our experts break down the problems – as well as solutions -- to make sure you get all the pay you deserve for Medicare drug screening tests.

'Complexity' Leads Your Choice

In case your lab carries out drug screening meant for single or multiple drug classes by the means of any lab method except chromatography, you have a couple of HCPCS codes choices to report your work for Medicare beneficiaries in 2011:

G0431 (revised) – i.e. Drug screen, qualitative; multiple drug classes as a result of high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter

G0434 (new) -- i.e. Drug screen, not including chromatographic; any number of drug classes, with CLIA waived test or moderate complexity test, per patient encounter.

It seems that you should select between these HCPCS codes based on the CLIA complexity categorization of the definite lab test you're using
You must report only one unit of G0431 or G0434 per patient encounter, despite of the figure of drug classes you distinguish.

The Clinical Laboratory Fee Schedule (CLFS) has priced G0431 at five times G0434 (national limit amount $102.33 versus $20.47).

Chromatography Gets Mixed Signals

Regardless of pricing 80100 on the CLFS, the Medicare Physician Fee Schedule (PFS) registers 80100 (Drug screen, qualitative; multiple drug classes chromatographic method, each procedure) by means of an "I" (invalid) code status indicator. That implies that the code is invalid for Medicare Purposes. Medicare uses a different code for reporting of, and payment for, these services

On the contrary, when Medicare pays for a code on the CLFS, you'll find the code that is listed on the PFS with status indicator "X". That implies that the code may be paid on a dissimilar fee schedule, like the CLFS, as the code signifies a service that is not in the statutory definition of 'physician services.

Best guess: It appears like Medicare desires labs to use G0431 for chromatography in place of using 80100

Problem: Even though the G0431 definition could include chromatography -- a high complexity test -- the code necessitates "multiple drug classes," which the lab may not always carry out. However you couldn't use G0434 as it states "except chromatographic."

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