Drug Screen Reimbursement

Welcome to the third article in the series focusing on laboratory operations in Pain Management practices.  In this article we will outline reimbursement for Urine Drug Screen Testing.

As with any service submitted for reimbursement, the procedure must meet Medical Necessity requirements, be assigned a payable diagnosis code (ICD-9) and be billed out with the appropriate CPT code. 

Reimbursement varies per region so please check the Clinical Laboratory Fee Schedule (CLFS) for your state or locality’s Medicare rate. The fee schedule can be found at: www.cms.gov › Medicare  › Clinical Laboratory Fee Schedule

For practices with a CLIA Certificate of Waiver performing point-of-care rapid cups, it is important to ensure that the rapid cups you are using are CLIA-waived by checking the product insert that comes with the product.  Also, please note that you can assign only one billing code per patient encounter, regardless of the number of drugs tested with the screening cup.

  • For Medicare use code G0434 and for non-Medicare use code 80104.
  • The description for the billing point of care code is: Drug screen, other than chromatographic; any number of drug classes, by CLIA-waived test or moderate complexity test, per patient encounter.
  • Maximum Medicare reimbursement per the Clinical Lab Fee Schedule is $20.60.  Again, be sure to check your local rate in the CLFS.

For practices using automated instrumentation to perform high-complexity qualitative or quantitative testing, billing and reimbursement is more complex.  The laboratory must have a CLIA Certificate of Compliance and (depending on your state) a state Clinical Laboratory License.

  • For Medicare use code G0431 and for non-Medicare use code 80101 times the number of drug classes being tested.
  • The description for the billing code for qualitative testing with automated instrumentation is: Drug screen, qualitative, multiple drug classes by high complexity test method (e.g. immunoassay, EIA) per patient encounter. For 
  • Maximum Medicare reimbursement is $102.40. For quantitative testing each drug tested is submitted for payment with an individual billing code.

Each code has an associated description and allowable reimbursement. A few examples are:

83295 Opiate(s), drug and metabolites, each procedure  $27.56
82145 Amphetamine or methamphetamine $21.87
83840  Methadone $23.13

 

Quantitative drug codes pay an estimated $19.40 - $27.38 per test assayed.

For a typical, 15-drug screen panel the estimated reimbursement per patient sample is $291.00.  Following in-house testing, if you send out specimens for supplemental testing, ensure that your reference laboratory only performs and bills for chromatographic procedures, such as gas chromatography/mass spectrophotometry, to avoid duplicate billing for quantitative testing, which can potentially result in payment denials.

Successfully operating a physician office laboratory involves a number of aspects. Ensuring that your billing is correct will protect you’re the reimbursement payments that will support continued laboratory operations.