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Summary of Pathology and Clinical Laboratory Changes: CMS Final Determinations for 2016 Work Comp Fee Schedule

February 26, 2016 by Catherine Montgomery

Pathology and Clinical Lab Changes

Effective January 1st, 2016, California workers’ comp adopts Medicare’s 2016 Clinical Laboratory Final Determination. Read on for a summary of the following changes, including critical changes for some pathology codes:

  • 3 deleted G-codes, replaced by 7 new G-codes for drug testing
  • 3 new procedure codes for presumptive drug testing
  • 4 new procedure codes for definitive drug testing
  • Other new and reconsidered test codes

Find all these changes on the DWC’s website, in the Pathology and clinical laboratory section of the OMFS webpage.

CMS Medicare CY2016 Clinical Laboratory Final Determinations

Deleted Drug Testing Procedure Codes

First, Medicare’s Final Determination DELETED the following drug testing codes:

  • G0431
  • G0434
  • G6030 through G6058

To replace the deleted codes, there are now seven new G-codes for drug testing.

3 New Presumptive Drug Testing Procedure Codes

Presumptive drug testing is “testing for drugs of abuse that relies on a structure of ‘screening’.” Medicare’s Final Determination added 3 new procedure codes for presumptive drug testing:

  1. G0477
  2. G0478
  3. G0479

NOTE:  Medicare’s Final Determination mandates that only 1 of these 3 presumptive codes may be used per day.

The table below lists the reimbursements for the new presumptive G-codes.

3 New Presumptive G-Codes

HCPCS

Testing

Reimbursement Amount

Daily Limit

Description

G0477

Presumptive Drug Testing

$17.83

Only one of the three presumptive G codes may be billed per day.

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.

G0478

Presumptive Drug Testing

$23.77

Only one of the three presumptive G codes may be billed per day.

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.

G0479

Presumptive Drug Testing

$95.10

Only one of the three presumptive G codes may be billed per day.

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.

4 New Procedure Codes for Definitive Drug Testing

Definitive drug testing is “quantitative testing that identifies the specific drug and quantity in the patient.” Medicare’s Final Determination added 4 new procedure codes for definitive drug testing:

  1. G0480
  2. G0481
  3. G0482
  4. G0483

NOTE: Medicare’s Final Determination also mandates that only 1 of these 4 definitive codes may be used per day.

The table below lists the reimbursements for the new definitive G-codes.

4 New Definitive G-Codes

HCPCS

Testing

Reimbursement Amount

Daily Limit

Description

G0480

Definitive Drug Testing

$95.92

Only one of the four definitive G codes may be billed per day.

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.

G0481

Definitive Drug Testing

$147.58

Only one of the four definitive G codes may be billed per day.

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.

G0482

Definitive Drug Testing

$199.23

Only one of the four definitive G codes may be billed per day.

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.

G0483

Definitive Drug Testing

$258.27

Only one of the four definitive G codes may be billed per day.

Drug test(s), definitive, utilizing dru 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.

Other New and Reconsidered Test Codes

In addition to the new Drug Testing rules, California workers’ comp also adopted the Other New and Reconsidered Test Code listed in Medicare’s Final Determination.

In our recent webinar on 2016 Changes to the Fee Schedule and Physician Forms, we did not have time to cover this information. Because this information is important for pathology billers, I wanted to cover the new pathology codes in Daisy News.

The table below crosswalks the old procedure codes (before January 1st, 2016) to the new procedure codes (on or after January 1st, 2016).

Before January 1st, 2016

On or after January 1st, 2016

G0464

81528

80081

85025 PLUS 87340 PLUS 87389 PLUS 86762 PLUS 86592 PLUS 86850 PLUS 86900 PLUS 86901, OR 80055

80055

85025 PLUS 87340 PLUS 86762 PLUS 86592 PLUS 86850 PLUS 86900 PLUS 86901

G0472

86803

81162

81211 TIMES 0.90 PLUS 0.90 TIMES 81213.

81170

81235

81218

81235

81219

81245

81272

81235

81273

81270.

81276

81275

81311

1.50 TIMES code 81275

81314

81235

81528

81315 PLUS 81275 PLUS 82274

81535

Crosswalk to 2 TIMES 88239 PLUS 87900

81536

87900

In section B of Medicare’s Final Determination, CMS lists a number of CPT codes which become gapfilled as of January 1st, 2016. Per 42 CFR 414.508, gapfilling occurs “when no comparable existing test is available.”

For a gapfilled code, during the first year of the test code, CMS establishes carrier-specific amounts for the new test code. During the second year, the test code is paid at the national limitation amount, which is the median of the carrier-specific amounts.

Good News: The decision to gapfill the codes requires cost inputs to be evaluated on a test-by-test basis, which often results in higher payments.

The gapfilled codes include:

  • 81412
  • 81432
  • 81433
  • 81434
  • 81437
  • 81438
  • 81442
  • 81490
  • 81493
  • 81525
  • 81538
  • 81540
  • 81595
  • 0009M
  • 0010M

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