The Office of Inspector General (OIG) added to its Workplan items that contractors will audit or evaluate with a more critical eye. If you bill for urine drug test or speech-language pathology services to Medicare beneficiaries, now’s the time to weigh your compliance risk and fix any issues.

OIG Scrutinizes Urine Drug Test, Speech-Language Pathology

You’ll need to pay attention to two new Medicare Part B watch items. In 2020, tCMS and private payers will begin review of:

• urine drug testing services
• payments for speech-language pathology

Good news: You’ve still got time to run internal audits, improve your practices, and show you’re making progress in compliance. Be prepared to respond to documentation requests, paybacks, and penalties.

Double Check Billing for Specimen Validity + Urine Drug Test

The OIG plans to review urine drug testing (UDT) services for Medicare beneficiaries with Substance Use Disorder (SUD)-related diagnoses. The codes for urine drug tests include specimen validity testing. So you generally would not bill for both tests at the same time.

The problem: The OIG found that many practices were incorrectly billing the tests together.

The 2018 Medicare fee-for-service improper payment data showed that laboratory testing, including UDT, had an improper payment rate of almost 30 percent, and that the overpayment rate for definitive drug testing for 22 or more drug classes was 71.7 percent.

Action: Review that you are correctly coding and billing specimen validity testing, when done as a part of drug testing.

When a specimen validity testing is used in the management of certain medical conditions, it can be billed separately. When it is used in conjunction with a urine drug test to identify specimen tampering, it is not.

Define Urine Drug Test vs Specimen Validity

Physicians use UDT to investigate for drugs in a patient’s system, and the results of the test will influence future treatment options. Some patients tamper with the urine samples to try and pass the test. While both urine drug test and specimen validity test require a urine sample, there are some key differences:

• A urine drug test identifies the presence or absence of or the quantity of drugs in a body.
• A specimen validity test identifies if a urine sample is a valid human urine specimen. While abnormal results can detect a medical condition, they are often helpful in identifying sample tampering as well.

Code Urine Drug Test Screening with CPT Codes 80305-80307

CMS rereleased the Medicare Learns Article on UDT to remind practices of proper billing. Current coding for testing for drugs of abuse relies on a structure of “screening” (known as “presumptive” testing) and “quantitative” or “definitive” testing that identifies the specific drug and quantity in the patient.

Report presumptive drug testing with CPT codes 80305-80307. These codes differ based on the level of complexity of the testing methodology and as the bold indicates include sample validation. Presumptive drug testing codes are for any number of drug classes; any number of devices or procedures and include:

• 80305: Presumptive drug tests that are capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.
• 80306: Presumptive drug tests that are read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.
• 80307: Presumptive drug tests, qualitative, that are read by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography, includes sample validation when performed, per date of service.

Note: Only one code from this code range may be reported per date of service. Bold added for emphasis.

Report Urine Drug Definitive Test as HCPCS Codes G0480-G0483

Definitive drug testing is reported with HCPCS codes G0480-G0483. All codes include the descriptor: 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 (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing.

Definitive drug testing codes differ on the number of drug classes tested:

• G0480: 1-7 drug classes, including metabolites if performed
• G0481: 8-14 drug classes, including metabolites if performed
• G0482: 15-21 drug classes, including metabolites if performed
• G0483: 22 or more drug classes, including metabolites if performed

Note: Only one code from this code range may be reported per date of service. Additionally, G0659 is for laboratories that are performing a less sophisticated version of these tests than drug testing laboratories:

• GO659: 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), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes

Apply Modifier KX When Needed Speech-Language Pathology Claims Exceed Threshold

The OIG plans to evaluate outpatient speech therapy service claims that are billed with modifier KX to determine whether the claims using the KX modifier adhere to federal requirements and to uncover any potentially unallowable billed services.

Federal Guideline: When Medicare payments for a beneficiary’s combined physical therapy and speech therapy exceed an annual therapy spending threshold ($2,040 in 2019), the provider must append modifier KX to the appropriate HCPCS code reported on the claim.

What’s modifier KX: The modifier indicates that the beneficiary’s combined physical and speech therapy services have exceeded their annual spending threshold, but the services being provided are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.