Medical Billing and Coding Healthcare Blog

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.

The Centers for Medicare & Medicaid Services (CMS) has released a video that contains guidance to help providers bill correctly for enteral infusion pumps.

Medicare Part B covers enteral nutrition supplies and equipment (feeding pump) under the prosthetic device benefit.

The two-minute video discusses Medicare coverage criteria for enteral infusion pumps and the four pieces of information necessary for proper documentation.

As CMS noted in September, there are a number of reasons for denial:

  • The patient must have a permanent (ordinarily at least three months) non-function or disease of the structures that normally permit food to reach the small bowel or a disease of the small bowel which impairs digestion and absorption of an oral diet. Either condition must require tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient’s overall health status.
  • When the method of administration is via enteral infusion pump, there must be documentation in the medical record to justify the use (for example, gravity feeding is not satisfactory due to reflux and/or aspiration, severe diarrhea, dumping syndrome, administration rate less than 100 ml/hr, blood glucose fluctuations, circulatory overload, gastrostomy/jejunostomy tube used for feeding). If the medical necessity of the pump is not documented, the pump will be denied as not reasonable and necessary.
  • The enteral nutrition must be infused 7 days per week. Documentation requirements include a detailed written order (DWO) for each item billed that must be signed and dated by the treating physician and a DME information form (DIF), which has been completed, signed, and dated by the supplier. Both of these must be kept on file by the supplier and made available upon request.
  • A new initial DIF for a pump is required when: a formula billed with a different code, which has not been previously certified, is ordered; enteral nutrition services involving use of a pump are resumed after they have not been required for two consecutive months; or a beneficiary receiving enteral nutrition by the syringe or gravity method is changed to administration using a pump
  • A revised DIF for enteral nutrients is required when: the number of calories per day is changed; the number of days per week administered is changed; the method of administration (syringe, gravity, pump) changes; the route of administration is changed from tube feedings to oral feedings (if billing for denial); or the HCPCS code for the current nutrient changes.

The video is part of a series intended to help providers improve in areas identified with a high degree of noncompliance.

Struggling to get paid for your gastroenterology medical billing claims? Contact PGM, which has a long history of success with both gastroenterology billing and endoscopy billing.

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