By Marla Durben Hirsch, contributing writer
If you bill for specimen validity testing done in conjunction with drug testing, heads up: the Centers for Medicare & Medicaid (CMS) has taken the rather unusual step of issuing a “reminder” on how to do so correctly.
Specimen validity testing is used to analyze urine specimens and determine whether they’ve been adulterated or tampered with.
In a new Special Edition MLN Matters article, issued on March 29, 2018, CMS reiterates Medicare’s policies regarding correct coding and instructions for billing specimen validity testing when done as part of drug testing.
The article, SE18001, first lays down the groundwork: Services that Medicare pays for must be reasonable and necessary, and clinical lab services must be ordered and used by the physician who is treating the patient or by a qualified ancillary practitioner. Current coding for testing for “drugs of abuse” relies on (1) screening (known as presumptive testing, CPT codes 80305- 80307) and (2) quantitative or “definitive” testing that identifies the specific drug and quantity of it in the patient (HCPCS codes G0480-G0483). Only one code from each code range may be reported per date of service.
There’s also a definitive drug testing code, G0659, that was created to recognize labs that are performing a less sophisticated version of these tests. The work performed in this test approximates the work performed in CPT code 80307.
Importantly, “providers performing validity testing on urine specimens utilized for drug testing shall not separately bill the validity testing.”
The agency stresses that this is not a policy change, but serves as a reminder of Medicare requirements. CMS implores providers to “please make sure your billing staffs are aware of these instructions.”
Topic a New Sore Spot for CMS
SE18001 itself doesn’t state why it issued this particular reminder, but a quick look at the references at the end of the article reveals what’s going on. The Department of Health and Human Services’ Office of Inspector General (OIG) recently reported that CMS had improperly paid 4,480 labs and physician offices a whopping $66.3 million for these tests from 2014 to part of 2016.
Even after CMS updated its automated system edits to identify and prevent these improper payments in 2016, OIG still identified $1.8 million in improper payments from April 1 through December 31 of that year.
OIG also found that at this rate, CMS would lose $12.1 million due to such improper payments over a five-year period. Ouch.
What physicians can expect
While the OIG has had lab testing (and lab/physician deals) in its cross hairs for years, this is yet another lab testing issue that will now come under increased scrutiny.
And while this reminder about urine testing may be spurred by the OIG report, it’s also likely due in part to the fact that more physicians are conducting or ordering these tests in light of the current focus on opioid addiction and substance abuse disorders. This also puts more pressure on CMS to pay for them correctly.
If you have billed for these tests in the past, expect your Medicare Administrative Contractor to take another look at those claims. The OIG specifically recommended that CMS instruct the Medicare contractors to recover the improper payments. You may want to conduct a self audit and double check that you complied with these billing rules.
And if you currently bill for these tests, make sure that you’re doing so correctly. CMS will be taking a closer look at them. And the fact that CMS just issued a “reminder” indicates that CMS expects everyone to know the drill.