THE HEAT IS ON...
ensure their billing platforms are compliant
with payor guidance and industry standards.
made to the current system of edits designed
to guard against program vulnerabilities; and
(3) review existing edits to ensure they prevent
claims with invalid and ineligible ordering
physician numbers from being paid.
Recent Payor Medical Policies
and Redrafting of Local
Coverage Determinations
Criminal Investigation of Inappropriate
Billing and Device Misbranding
Payers - government and commercial have also been very active in setting medical
policies and publishing new local coverage
determinations (LCDs) on the topic of Drug of
At the same time, the US Department of
Justice (USDOJ) and the Federal Bureau of
Investigations (FBI), have been busy with a
Abuse Testing. Palmetto GBA, Noridian, Novitas,
Blue Cross Blue Shield (various locations), and
some Medicare Advantage programs
nationwide have all issued updated coding and
reimbursement guidance documents on the
topic of testing for drugs of abuse. Payers have
also initiated overpayment requests for the
billing of qualitative and quantitative drug
testing, under a variety of CPT and HCPCS codes,
including CPT 80101, 80102, 80104, and HCPCS
Codes G0434 and G0431.
While many of the referenced guidance
documents are still in draft form, the common
theme seems to be an increased focus on
medical necessity, drawing boundaries
around testing frequency, and requiring more
individualization in drug testing platforms.
Commercial payers appear to favor using
Medicare’s G0431 HCPCS code for high
complexity qualitative drug screening instead
of allowing individual units of CPT 80101.
Finally, some Medicare Advantage plans now
want medically necessary confirmation
testing coded under CPT 80102, instead of the
specific analyte or method codes for
quantitative testing. In fact, at least one plan
(Windsor) has stated that it considers the
submission of claims with multiple qualitative
and quantitative codes to constitute
unbundling. It is fair to say that the
inconsistent approaches to guidance
documents is not helping clinical laboratory
in the drugs of