Changes Coming for Documentation of Laboratory Testing

If your laboratory performs toxicology procedures to test for drugs of abuse, you have most likely become aware of the new Procedure-to-Procedure (PTP) edits effective July 1. The third-quarter National Correct Coding Initiative (NCCI) table updates were posted to the Centers for Medicare & Medicaid Services (CMS) NCCI PTP webpages for Medicare and Medicaid on June 1.

For many laboratories, the updates to toxicology billing edits went unnoticed until the effective date, when claims processing stopped claims for definitive test procedures (G0480-G0483, G0659) if billed on the same claim as a presumptive test (80305, 80306 or 80307). Historically, laboratories have billed the two procedures together, as allowed by medical indication (see Local Coverage Determinations for your Medicare Administrative Contractor/MAC). Effective July 1, the presumptive test became the payable (column 1) procedure of the code pair, with no modifier allowed for billing of the definitive analysis.

Revisions Expected

CMS announced on July 10 that retroactive changes will be made to the NCCI PTP edits between Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480-G04083 and G0659 for definitive test(s), to allow the use of an appropriate NCCI modifier.

For the time being, however, laboratories must append a suitable modifier if billing for both presumptive and definitive drug of abuse analysis on a single date of service. Before appending a modifier, be certain you are familiar with the payer guidelines for coverage of the definitive test procedure. Many payers, including Medicare, Medicaid, and commercial plans, have updated coverage policies to include details for billing of definitive tests that are targeted at specific drugs or drug classes where no presumptive method exists for detection, versus confirmative testing to validate the results of a presumptive analysis.

Concerns of Abuse for Billed Procedures

Abusive billing practices by some providers has raised concerns with payment for unsupported and/or undocumented services for such testing. Now is the time to review your internal policies for required information to be documented by the ordering provider, as well as your laboratory policy for testing protocols. 

Laboratories should be prepared to supply documentation of physician orders that support each drug or drug class that is tested, reported, and billed as definitive testing. For some payers, the determination of the code to be billed will be based on the indication for testing. For instance, some payers specifically instruct to bill with a specific CPT®, as defined by the American Medical Association (AMA), if performing targeted definitive test(s) for a drug or drug class that is not able to be detected by a presumptive method – but if performing a confirmation of drug class(es) detected by presumptive measure report, this testing takes place with a HCPCS, as defined by G0480-G04083 or G0659.

A review of provider ordering trends is recommended to ensure that the laboratory is not receiving “blanket orders” from a provider or providers that give the same order for all patients seen and treated in their practice. Note that most payers will consider a “routine standing order” for all patients of a provider’s practice to not meet the conditions that support medical necessity.

Utilize results from the Medicare Comprehensive Error Rate Testing (CERT) program and findings that have resulted in an increase of denials related to substance monitoring and drug abuse testing. Among the often-cited reasons for denial are:

1. Insufficient or no documentation to support intent to order the test and/or medical necessity for the test of the individual patient;
2. Unsigned medical record documentation by the treating physician or non-physician practitioner;
3. Blanket orders not for a specific patient, without individual decision-making at every visit; and
4. Routine standing orders for all patients in a physician’s practice.

Notification of Replacement Files

CMS has posted statements to the Medicare and Medicaid websites advising laboratories of the current state (no modifier for bypass of edit) and the future state for publication of revised edits that will allow for use of a modifier to bypass the edit. Once published, the change will be retroactive to July 1, 2023. This notice advises that laboratories be familiar with the circumstances that support use of a modifier to bypass the edits and bill the presumptive and definitive codes together. The Medicare claims processing systems will implement this change effective Oct. 1, 2023.

Claims Processing Instruction

The notice posted by CMS supplies the following instruction: “if laboratories bill the MACs for these tests together on or after July 1, 2023, and believe that an NCCI modifier is appropriate, the lab should include the applicable modifier on the claim. The MACs will adjust those claims with dates of service between July 1, 2023, and Oct. 1, 2023, to allow payment when an NCCI modifier was used. Alternatively, a laboratory may also choose to use the MAC appeals process if it does not wish to wait for the automatic adjustment to occur, or it can wait to submit its claims until CMS implements the change.”

With reimbursement continuing to be targeted and compliance under threat, accurate coding and compliance knowledge is a safeguard to reinforce full revenue. Master more laboratory coding and compliance challenges by purchasing our Coding Essentials for Laboratories for success throughout 2024.