EK HEALTH

Guest Editorial: Richard Martin, MD, MPH is a senior EK specialty reviewer. He is board-certified in Occupational Medicine and holds an MPH. Dr. Martin completed both his occupational medicine training and his MPH at UCSF. He has a special interest in urine drug testing and billing because he so often sees abuse and misuse in this practice niche.

Urine drug screening (UDS) for the concurrent use of illicit drugs, in addition to addictive, but legal, prescription drugs is often an inappropriately utilized and billed medical service. A UDS is used to answer several questions: Is the patient taking the prescribed medications? Is the patient taking prescription medication(s) not being prescribed? Is the patient taking illicit drugs? The following brief highlights may assist you in dealing with this issue from a utilization review and billing perspective:

1. UDS is not mandatory for patients on scheduled drugs, but it is recommended by MTUS.  It is extremely important that it is ordered and collected correctly. The current frequency of testing and poor quality control is often driven by misguided billing practices and the hope for unrealistic (and unconscionable) profits secondary to this testing. However, when I see bills for over $1,000 for a UDS perhaps it is more profitable than imagined.

2. RAND supported guidelines have recently published a recommendation for drug testing.  Occupational Disability Treatment Guidelines (ODG) provide a framework that demands good rationale before performing, confirming and repeating UDS.

3. The guidelines allow for a few billing standards to be applied to UDS.  These are as follows:

A. Point of collection (POC) testing (often called dip stick testing)

This is generally performed with a single dip stick that screens for multiple drug classes using an immunoassay technique.  The correct CPT billing code is 80100 which includes the complete screen.  Each individual drug is not to be billed separately as CPT 80101.  The difference is about a $40.00 payment vs. $800.00 or more for materials that cost about $10.00 -$12.00.

• CPT 80100 “Drug screen, qualitative; multiple drug classes chromatographic method, each procedure.” OMFS page 400.

• MAG Mutual Ground Rule for CPT 80100 “However, if multiple drugs can be detected using a single analysis use only CPT 80100, once.”  This is the same as the Medicare Ground rule.  2010 MAG Mutual Physicians Fee Guide page 677.

• In 2010 CMS (Center for Medicare/Medicaid Services) has published new codes for POC screens. G0430 is for a multiple drug screen qualitative, other methods (cross walk to CPT 80100).  G0431 is to be cross walked to CPT 80101.

B. Referrals to reference labs.

If the POC drug screen is consistent with the prescribed medications and there are no aberrant drug behaviors, a denial of the complete reference lab testing is reasonable. In the vast majority of cases there is no medical reason to confirm a + UDS for a prescribed medication either quantitatively or qualitatively.

If the POC drug screen reveals the presence of an illicit drug, then confirmatory testing specifically for this drug only is authorized.  Other legitimate billing may be a UA or urine creatinine for quality control to assure that the sample tested is truly urine.  Repeat testing and screening for multiple drug classes is not medically necessary.

Unless there is specific documentation of suspected diversion or the EE is on massive quantities of potentially addictive medications, routine quantitative testing is unnecessary and should be denied unless unique supportive circumstances are documented.  Quantitative testing can be very useful, but this is rare and should be reserved for specific circumstances.

As a reviewer, it may be necessary to delve into numerous CPT codes and address each one separately. At other times it is more efficient to approve the few legitimate specific CPT codes and recommend a denial of any other codes without specifically recalling and reviewing each one.

In summary: It is clear all billing and coding for UDS should be carefully scrutinized. New published guidelines allow for a rational approach to their utilization review and for subsequent billing issues in association with drug testing.