2017 Clinical Toxicology Laboratory Fee Schedule Changes- The Good and the Bad

 

Hartford, CT – January 5, 2017

There are a number of changes to the Toxicology Clinical Lab Fee Schedule for 2017.  So let’s start with the bad news first. Along with fee (allowable) changes, there are once again laboratory coding changes. Details are below, however, the biggest change for toxicology laboratories has to do with the G codes for toxicology screening tests.

 

Billing Codes G0477, G0478 and G0479 have all been deleted this year. These are screening codes and not confirmation codes. They have been replaced by a new set of CPT codes as follows: CPT Code 80305, 80306, 80307.  There are newly established corresponding payments as outlined below as well.

 

New codes always tend to create confusion as Medicare intermediaries and commercial insurance payers update their systems. Therefore, laboratory billing offices or services must update their billing systems accordingly and follow-up aggressively on claims. To compound the confusion even further, some commercial payers may lag in updating their systems from older code sets to the new ones, and therefore laboratory billing staff must differentiate coding sets by payer according to each individual insurance payers’ requirements.

 

In regards to toxicology confirmation / definitive testing, Medicare will continue to utilize the 2016 G Code sets including codes G0480 through G0483.  Laboratories must keep in mind that certain payers utilize this code set, while other use a separate CPT code set (which does not cross walk to the G Code Set).  Laboratories should have excellent billing resources knowledgeable in the specific requirements of each payer in order to optimize revenues.

 

Now for some potential good news. According to NILA estimates, CMS rates for confirmation / definitive toxicology testing are scheduled to increase in 2017. Although the official schedule has not been published, this is excellent news. The new estimated rates are outlined below.

 

Following are the specifics for changes to the toxicology codes and fee schedule for 2017:

 

The following CMS HCPCS codes will be deleted as of January 1, 2017:

 

Code: G0477 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.

 

Code: G0478 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.

 

Code: G0479 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service.

 

CMS will recognize the new Presumptive Drug Class Screening as defined by AMA CPT 80305-80307

 

Presumptive Drug Testing:

 

Code: 80305 Drug tests(s), presumptive, any number of drug classes; any number ofdevices or procedures, (eg immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service)

Code: 80306 (Drug test(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures, (eg, immunoassay) read by instrument assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service)

Code:  80307 (Drug test(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service.)

 

 

 

 

CMS will not recognize the Definitive Drug Class Listing AMA CPT codes of: 80300-80377 but will continue to use the below CMS HCPCS codes.

Definitive Drug Testing:

Code: G0480 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed.

 

Code: G0481 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed.

 

Code: G0482 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed.)

 

Code: G0483 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed.

 

The following amounts are projected reimbursements based on CMS approval of the new crosswalk codes for screenings and rate increases effective 1/1/2017 as published by NILA. Please note the

Clinical Diagnostic Laboratory Fee Schedule for 2017 as not yet been published.

 

(Screenings/Presumptive)

80305  $14.86

80306  $19.81

80307  $79.25

 

(Confirmations/Definitive)

G0480 (1-7) $116.85

G0481 (8-14) $159.90

G0482 (15-21) $202.95

G0483 (22 &>) $252.15