CMS Increases Definitive Drug Testing Reimbursement

The Centers for Medicare & Medicaid Services (CMS) will increase reimbursement for toxicology drug confirmation codes in 2017.

Background

For 2016, CMS implemented four new HCPCS G codes for definitive drug testing:

  • G0480
  • G0481
  • G0482
  • G0483

CMS priced these codes using a crosswalking formula. The first two tests performed were paid at the full price of the crosswalk CPT code 82542 and the remaining tests within that code were paid at 25% of the crosswalk price.

CPT Code

Crosswalk Formula

G0480

2*82542 + 5*.25*82542

G0481

2*82542 + 12*.25*82542

G0482

2*82542 + 19*.25*82542

G0483

2*82542 + 27*.25*82542

Changes for 2017

CMS is modifying the current formula to establish the price for these codes to allow four tests to be priced at the full crosswalk price:

CPT Code

Crosswalk Formula

G0480

4*82542 + 3*.25*82542

G0481

4*82542 + 10*.25*82542

G0482

4*82542 + 17*.25*82542

G0483

4*82542 + 25*.25*82542

CMS also modified the descriptors for the definitive  drug testing codes. They now read as follows (underlined text indicate additions):

G0480 — Drug test(s), definitive, utilizing (1) 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 (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control f or matrix ef f ects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control f or instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed

G0481 — Drug test(s), definitive, utilizing (1) 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 (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control f or matrix ef f ects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control f or instrument variations and mass spectral drif t); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed

G0482 — Drug test(s), definitive, utilizing (1) 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 (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control f or matrix ef f ects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control f or instrument variations and mass spectral drif t); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed

G0483 — Drug test(s), definitive, utilizing (1) 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 (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control f or matrix ef f ects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control f or instrument variations and mass spectral drif t); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed

Providers of a clinical lab billing service should note these and the other changes that were the result of the recent Annual Laboratory Public Meeting.


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