Tuesday, August 18, 2015

Clinical Laboratory Fee Schedule (CLFS) Update CPT 80300 through CPT 80377

Final Determinations
Codes 80300 through 80377  (63 codes)
Industry Recommendation: Various, from crosswalking to specific existing codes (e.g., G0434, G0431, etc.), to gapfilling.
CMS Recommendation: Delay in pricing.

Rationale: These codes represent various drugs of abuse testing codes, many of which are specific
to individual drug testing.

In the 2015 clinical laboratory fee schedule preliminary determinations file that we released to the public on October 9,2015, we proposed to not pay for new CPT codes for drugs of abuse tests. We stated our concern about the potential for over payment when billing for each individual drug test rather than a single code that pays the same amount regardless of the number of drugs that are being tested. Therefore, we recommended delaying pricing for these codes at this time, until further information and education is obtained.

Commenters have advised us that several of the tests reported by codes deleted by the CPT Editorial Panel were to be reported by the new codes that we are not recognizing. We continue to believe that we need additional time and input from the public to determine Medicare payment for drugs of abuse testing that will not lead to overpayment. Until such time, we believe that Medicare should not recognize the additional codes created by CPT for drugs of abuse tests. However, we agree with the commenters that there will not be sufficient codes available to bill for drugs of abuse tests if we finalize our proposal. For this reason, we are maintaining the 2014 status quo for 2015 and creating alphanumeric G codes to replace the 2014 CPT codes that are being deleted for 2015. For 2015, providers are to use these G codes in the same manner in which they used the corresponding CPT codes for 2014.

In addition, for some of the drugs of abuse testing codes, CPT did not delete the 2014 code
numbers, but revised the instructions or code descriptors in the 2015 CPT Manual. For billing
CLFS in 2015, we are instructing the public to use these codes exactly as they used them for 2014,
regardless of the 2015 instruction or code descriptor changes. The following are some examples of
the application of this policy:

• The prefatory language for the Therapeutic Drug Assay section of the CPT Manual changed between 2014 and 2015. In the 2014 CPT Manual, this section allows for testing urine specimens. In the 2015 CPT Manual, the section does not allow for urine testing. For 2015, bill Medicare according to the prefatory language that applied to the Therapeutic Drug Assay section of the 2014 CPT Manual.

• The procedure specific codes (chromatography, mass spectrometry, etc) for drug analytes
that are not specified elsewhere are in the Chemistry section of the 2014 CPT Manual.
The 2015 CPT Manual has prefatory and parenthetical language that instructs providers
to not use Chemistry section codes for drug screening tests (unless there is a specific analyte code) and refers them to the new CPT codes that we decided not to pay for in 2015. In one group of 4 codes, the descriptors have been changed to “non - drug.” For  2015, use the instructions in the Drug Testing section and Chemistry section of the 2014 CPT Manual and ignore the 2015 prefatory and parenthetical language, as well as the change in descriptors for CPT codes 82541, 82542, 82543, & 82544, that prohibit the use of CPT codes in the Chemistry Section for testing for drugs.

As we further consider coding and payment for these services in 2016, we will be looking to
balance beneficiary access with appropriate payment for medically necessary services under

the Medicare program.

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