When coding for toxicology, knowing when to use AMA and CMS codes is key as there can be great variance in reimbursement. In this post, you'll find more information on billing AMA versus CMS.
Bundling VS Unbundling
Drug Testing procedures are divided into three subsections:
Therapeutic Drug Assay, Drug Assay, and Chemistry-with code selection dependent on the purpose and type of patient results obtained. Therapeutic Drug Assays are performed to monitor clinical response to a known, prescribed medication. The two major categories for drug testing in the Drug Assay subsection are:
1. Presumptive Drug Class tests are used to identify possible use or non-use of a drug or drug class. A presumptive test may be followed by a definitive test in order to specifically identify drugs or metabolites.
2. Definitive Drug Class tests also known as confirmation tests are qualitative or quantitative tests to identify possible use or non-use of a drug. These test identify specific drugs and associated metabolites, if performed. A presumptive test is not required prior to a definitive drug test.
When coding as CMS (Bundling of the Drug Classes):
Report the following:
Presumptive Testing -(Only 1 Code Billed Per Day)
CMS Presumptive Testing Definition: CPT 80307 - Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, includes sample validation when performed, per date of service
Definitive - (Only 1 Code Billed Per Day)
G0480: 1-7 drug class(es)
G0481: 8-14 drug class(es)
G0482: 15-21 drug class(es)
G0483: 22 or more class(es)
CMS Definitive Drug Testing Definition: Definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers, including, but not limited to GC/MS (any type, single or tandem) and LC/MS and enzymatic methods, (2) stable isotope or other universally recognized internal standards in all samples and (3) method or drug-specific calibration and matrix-matched quality control material; qualitative or quantitative, all sources, includes specimen validity testing, per day; including metabolite(s) if performed
CMS listed these “drug classes” for definitive testing and decided to use a tiered system because of concerns about overpaying when laboratories bill for each individual test. CMS believed a single code that pays the same amount regardless of the number of drugs being tested would reduce overpayments. For example, if testing includes: Benzodiazepines, Amphetamines, Fentanyls, Ketamine; report G0480 (1-7 classes) since 4 classes were tested. If a presumptive test was performed with use of a chemistry analyzer instrument, report 80307 also. See the Definitive Drug Classes Listing Table for a listing of the more common analytes within each drug class, how to determine which drugs are included in a class, and how to code per drug class.
When coding as AMA (Unbundling of the Drug Classes):
Report the following:
Presumptive – (Only 1 Code Billed Per Day)
AMA Presumptive Testing Definition: CPT 80307 - Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, includes sample validation when performed, per date of service
Definitive – (Multiple Codes Billed Per Day)
AMA Definitive Testing Definition: See the Definitive Drug Classes Listing. This provides the drug classes, their associated CPT codes, and the drugs included in each class. Each category of a drug class, including metabolite(s) if performed (except stereoisomers), is reported once per date of service.
These codes are considered unbundled due to the fact that drug classes may contain one or more codes based on the number of analytes. For example, an analysis in which five or more amphetamines and/or amphetamine metabolites would be reported with 80326. The code is based on the number of reported analytes and not the capacity of the analysis.
To report amphetamine and methamphetamine using any number of definitive procedures, report 80324 once per facility per date of service. To report codeine, hydrocodone, hydromorphone, morphine using any number of definitive procedures, report 80361 once per facility per date of service. To report codeine, hydrocodone, hydromorphone, morphine, oxycodone, oxymorphone, naloxone, naltrexone performed using any number of definitive procedures report 80361 X 1, 80362 X 1, and 80365 X 1 per facility per date of service. To report benzoylecgonine, cocaine, carboxy-THC, meperidine, normeperidine using any number of definitive procedures, report 80349 X 1, 80353 X 1, and 80362 X 1 per facility per date of service. See the Definitive Drug Classes Listing Table for a listing of the more common analytes within each drug class.
Below is an example of billing AMA VS CMS and the difference in reimbursement. Also, please note, that the majority of payers that allow AMA coding also have the CMS codes listed on their fee schedules and it takes only the most experienced and educated RCM company to educate the Laboratory on when to Bundle VS Unbundle.
Billing to Capital Blue Cross of PA
CBC Reimbursement – CMS Code
G0482 - $104.34
CBC Reimbursement – AMA Codes
80345 - $9.55
80355 - $10.55
80348 - $15.49
80354 - $15.49
80372 - $15.49
80358 - $12.96
80373 - $15.49
80362 - $15.68
80353 - $11.11
80321 - $10.55
80356 - $15.49
80359 - $10.55
83992 - $11.72
80323 - $23.66
80360 - $10.55
80332 - $10.55
80371 - $10.55
80352 - $10.66
As you can see by the example, using the right codes makes a huge difference in reimbursement and can also help improve cash flow by decreasing coding denials. If your lab is struggling with toxicology billing and/or coding, Coronis is here to help. Click below to schedule a free consultation.