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Billing Correctly for Urine Drug Screen

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Coming on board to a Pain office and am little confused about how to go about billing correctly for urine drug screens (UDS). 

In the past, when a doc requests a UDS, it is collected in a urine cup, which essentially runs about 10-15 common drugs via strips that are already present in the cup.  We bill either 80101 +/- 12 units or G0434 +/- modifier QW depending on the insurance carrier.  The urine is then sent out a lab for confirmation.

Now, we have an in-office high complexity, CLIA certified lab.  So, instead of having the urine being sent out, it will essentially go to a room in our office.  What is the proper way to capture charges in this situation?  Should we still do the cups and bill as we did, AND charge an additional code for this testing now being done in our lab?  If so, what codes?

Any insight into this is greatly appreciated.


It is my understanding that any Lab that does not meet the CMS definition of a Physician Office Lab (POL) must be a stand-alone unit - with its own Employer ID # and Type 2 NPI Number.  The lab itself is a billing entity and must do its own billing.  So far as I know, this requirement does not vary across state lines.

So - for starters, the first thing to determine is whether your in-house lab meets the CMS definition of a Physician Office Lab.  If it does not, the lab itself must do the billing.

The tests previously done in-house were likely CLIA-Waived tests with strips in the cup.  Those waived tests are billed differently than the test done by the labs your docs sent the samples to for confirmation.  The in-house tests could only be billed with one code per cup (CLIA-Waived tests), regardless of the number of strips used.  The  outside lab likely billed for testing with automated instrumentation.  This billing would be one code per each drug class tested for.  This is likely the type of billing you will do for your new in-house lab.

If this new in-house lab is certified for high-complexity testing, it must have a lab director who knows what they are doing.  S/he can no doubt help you get up to speed if you will be doing the billing for the lab.  Meanwhile, does this help at all:
Coding Info:
Types of CLIA Certificates
Personnel Requirements for Clinical Labs

Thanks for chiming in.

The lab is indeed a stand-alone unit and can bill for itself.  We do have a director of the lab, but he is unfamiliar with the billing and coding aspect of the venture. 

I read the links and they are helpful.  I will provide a scenario and would like some input if I am doing it right.

New patient comes in.  Doc orders UDS.  We do CLIA Waved UDS in a cup for qualitative.  If Medicare, we bill G0434 and if other, we bill 80101. 

Now, urine is sent to the in-house high complexity lab.  Lab runs two quantitative drug tests for opiates and methadone (just to name two).  Lab now bills out 82395 and 83840.  If the lab ran more quantitative testing, each drug or drug class tested will be billed out separately. And these codes are the same for Medicare as well as other payors.

Is the above correct?

None of our clients do urine drug screens, and neither does the lab - so I cannot speak to the correctness of your scenario, other than confirming that it mirrors the advice given in the first link I gave you.

It is important that you get this right.  I would advise you to check with each of the carriers your lab bills to see what codes they want to see for each of the tests your lab will bill for.  The answers are going to be specific to whatever state you are in.

Having said that, there are some interesting conversations going on re. the questions you have asked if you Google on "quantitative testing" + billing.  For example, this link gives some pretty specific information, although you may already know most of it.  But it supports my advice to check with each carrier for what they specifically want.
  and this:

You might also consider asking COLA if they have any answers to your questions, or if they could refer you to resources for your state.

Thanks for chiming in again.

I will definitely check with my carriers about the specifics.

If the above scenario as I played it out is indeed correct, does the modifier 91 or modifier 59 have any role?

I doubt it, but I wanted to see if you had an idea. 

This is what I know about the 91 modifier:

Modifier 91 Fact Sheet
Repeat clinical diagnostic laboratory test
In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results.
Appropriate Usage
To identify a subsequent medically necessary laboratory test on the same day of the same previous laboratory test

Inappropriate Usage
Used for a rerun of a laboratory test to confirm results
Due to testing problems for the specimen
Due to testing problems of the equipment
When another procedure code describes a series test
When the procedure code describes a series of test
For any reason when a normal one time result is required

From what I understand, modifier 91 should not apply as we are now re-running tests to confirm or get quantitative values.  In addition, the coding is different i.e. 80101 vs whatever drug panel is being tested for.

I bring this up because I read somewhere than CMS will not pay for the same test if it is carried out twice on the same day....


Thanks again.


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