PractiSource Billing and RCM News Update February 1, 2016
For Immediate Release

The world of billing and reimbursement for Toxicology Laboratories has changed yet again for 2016.

Along with changes for both screening and confirmation codes, comes added confusion (on behalf of both insurance payers and labs) as well as changes in reimbursement for the services provided by toxicology screening and confirmation labs.
First and foremost, CMS (Center for Medicare Services) has completely revamped the entire coding structure for toxicology screens and confirmations. More on this in a moment. Before getting into the specifics of the 2016 toxicology billing G Codes, lets take a look at a little bit of history regarding billing for these services over the past few years.

“Part of the issue with toxicology screening and confirmation reimbursement has been the numerous changes to the related coding structures between 2013 and 2016” according to Kim Paradis, Revenue Cycle Manager at PractiSource. She continued, ” Between then and 2016, there have been no fewer than three major changes – and both insurance payers and laboratory providers have had a difficult time staying on top of these changes. In fact, certain payers have been slow to adopt newer coding sets, and have at times even accepted only a sort of hybrid of multiple coding sets.”

If it sounds confusing, it is. For example, some major payers switched to the 2014 sets of codes to the more confusing, but more descriptive 2015 toxicology CPT codes in early 2015. Some then (without informing the laboratories) changed to the G-code structure mid-year. Some even required that certain tests be billed with G codes, while others be billed with a CPT. Multiply this by hundreds of insurance payers, and keeping track of the changes, billing correctly, following up, and getting paid appropriately was and continues to be a daunting task which, if not performed correctly, leads to less than optimal reimbursement for the laboratory.

Now, throw in the 2016 billing changes, and matters get even more confusing. First, let’s give some credit to CMS for trying to simplify the coding structures. That said, now let’s take a look at the impact.

2016 Toxicology Billing / Coding Changes – The Impact:

First, the final determinations for the new toxicology screening and confirmation codes were released very late in the year. This provided little time for Medicare and other payers to adopt these new codes, set up their systems so they could be adjudicated correctly, and train their staff. This has led to a mess to say the least. Medicare and it’s intermediaries are struggling with the new codes as are commercial payers who have adopted these codes.

According to Kim Paradis, “We have seen several payers simply mis-adjudicating and/or denying correctly submitted, clean claims. Submitting a clean claim is simply not enough as it relates to toxicology laboratory services – aggressive claims followup with the payers is required to right these mistakes and ensure proper payment”.

If past is prologue, then this is not a one time issue with the payers, but requires constant attention to get paid appropriately.
Second, the new codes have corresponding payment amounts which are lower than historical payments for the same service overall. Details are below, however, suffice it to say that labs will be getting paid less for the same service. Look for future updates from PractiSource over the next two months for more details on this very subject and how labs can make up for these reductions in reimbursement.

Third, most industry experts agree that these changes will affect more than just Medicare, Medicaid and affiliated payers. As a billing and revenue cycle management company, we have seen similar changes over the years to a wide variety of medical specialties. In virtually all cases, when CMM cuts rates, it simply does not take long for other payers to follow them in their efforts to save costs. It may take weeks, months, or years (we wouldn’t bet on the later), but ultimately most insurance payers will attempt to justify lower rates by citing CMS’ rates and the reasoning behind them. This makes it more important than ever for laboratories to make absolutely certain that their billing and revenue cycle management is performing optimally and to make changes for the long term if needed.

Finally, the confusion alone surrounding the new billing rules will have a negative impact on revenue and cash flow for laboratories. Why? Because as claims are submitted incorrectly due to the confusion (or correctly, but not in accordance with each individual payers requirements), the denial or mis-adjudication rates will rise. Furthermore, the changes have, and will continue to have insurance payers paying claims incorrectly, or denying them altogether for incorrect reasons.

What can be done?

First and foremost, laboratories should review and improve their billing and reimbursement processes. As always, you must first make sure the the services you bill for accurately reflect the services performed. Next, perform an honest evaluation. How confident are you that your billing staff (whether in-house or outsourced) is familiar with all of the new rules and payer-specific complexities? Evaluate how aggressively you are pursuing unpaid, or incorrectly paid claims. How does your Accounts Receivable stack up against industry-leading key performance indicators (KPI’s). In sum, how confident are you that your are billing correctly, pursuing unpaid claims, and holding insurance payers accountable? With reimbursement rates declining, it is now more important than ever that all facets of your Revenue Cycle Management functions are geared toward maximizing revenue. If they are not, or if you are unsure, then perhaps having them evaluated and reviewed by an outside party would in order.

Also, if you are not sure you are maximizing revenue and setting up your RCM for long-term success, it may be worth looking into outsourcing your billing and revenue cycle functions to a reputable toxicology laboratory billing and RCM company, such as PractiSource (we needed to plug our services at least once in this article!). A good company will be happy to perform a free evaluation of your A/R, revenue and cash flow before ever recommending their services. While not the right fit for every laboratory, outsourcing to a company with extensive experience can benefit laboratories with substantially greater aggregate resources, automated systems, industry-specific knowledge, and improved data analytics – a requirement to making the decisions in this ever-changing environment. These are just some of the potential benefits.
Now, onto the specifics….

Specific Changes for Toxicology Clinical Laboratory Billing – 2016

The following information is a synopsis of changes to the 2016 Clinical Laboratory Fee Schedule Changes. Information was provided by CMS.

Deleted Codes

The following toxicology-related codes were deleted as of January 1, 2016

Code: G0431– Drug screen, qualitative; multiple drug classes by high complexity test method
Code: G0434 – Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test
HCPCS codes G6030-G6058
CMS will not recognize the for Definitive Drug Class Listing AMA CPT codes of: 80300-80377

The New Codes

Presumptive Drug Testing:
Code: G0477 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.

Code: G0478 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.

Code: G0479 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.

Definitive Drug Testing:

Code: G0480 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.

Code: G0481 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.

Code: G0482 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.)

Code: G0483 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, 22 or more drug class(es), including metabolite(s) if performed.

The Drug Classes

• Alcohol(s)
• Alcohol Biomarkers
• Alkaloids, not otherwise Specified
• Amphetamines
• Anabolic steroids
• Analgesics, non-opioid
• Antidepressants, serotonergic class
• Antidepressants, Tricyclic and other cyclicals
• Antidepressants, not otherwise specified
• Antiepileptics, not otherwise specified
• Antipsychotics, not otherwise specified
• Barbiturates
• Benzodiazepines
• Buprenorphine
• Cannabinoids, natural
• Cannabinoids, synthetic
• Cocaine
• Fentanyls
• Gabapentin, non-blood
• Heroin metabolite
• Ketamine and Norketamine
• Methadone
• Methylenedioxya mphetamines
• Methylphenidate
• Opiates
• Opioids and opiate analogs
• Oxycodone
• Phencyclidine
• Pregabalin
• Propoxyphene
• Sedative Hypnotics (nonbenzodiazepines)
• Skeletal muscle relaxants
• Stereoisomer (enantiomer) analysis
• Stimulants, synthetic
• Tapentadol
• Tramadol
• Drug(s) or substance(s), definitive , qualitative or quantitative, not otherwise specified;

The AMA CPT Manual may be consulted for examples of individual drugs within each class

2016 Toxicology Laboratory Screening and Confirmation Testing Payment Amounts
Based upon CMS’ information, we have calculated the approximate payment amounts for the screening and confirmation codes above. Please note that these are approximations based upon certain Medicare allowed amounts. Furthermore, different geographic regions have varied factors relative to payment amounts and therefore actual payment will differ from those listed.

The following amounts are taken from the 2016 Clinical Diagnostic Laboratory Fee Schedule:
(Screenings)
G0477 $14.86
G0478 $19.81
G0479 $79.25
(Confirmations)
G0480 (1-7) $79.94
G0481 (8-14) $122.99
G0482 (15-21) $166.03
G0483 (22 &>) $215.23

We hope the information in this article was useful and helpful. However, please note that you should not rely on this information from PractiSource for your final coding and billing determinations, as you should routinely consult and confirm all information with the latest, detailed published information from CMS.

About PractiSource:

PractiSource, LLC is a full service medical billing and revenue cycle management (RCM) dedicated to maximizing medical provider reimbursement with the highest levels of concierge-style customer service and support. The company provides services to clinical laboratories (including toxicology-specific laboratories), physicians and medical facilities. Headquartered near Hartford, Connecticut, PractiSource serves clients from coast to coast.

For more information or a free consultation, please contact info@practisource.com