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April 27, 2012

Billing for Drug Screens: G0431

Effective 04/01/2010 CMS implemented a new HCPCS code for drug screening; replacing the 80101 CPT code for Medicare use. CGS claim denial analysis and appeals data indicate an ongoing issue with the use of this code.

Beginning in calendar year 2011, G0431 is defined as: drug screen, qualitative: multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter

CGS continues to see the G0431 code billed on multiple claims for the same date of service for the same patient; billed with modifier-59 or -91 indicating a separate/additional screening on the same date of service, and multiple units billed. Per the code definition-G0431 is to be billed per patient encounter. Multiple units on the same date of service for a patient should be rare-and only acceptable when performed at a separate, medically necessary patient encounter.

G0431 represents a drug screening test that is classified as a CLIA (Clinical Laboratory Improvement Amendments) high-complexity test when performed using instrumented systems (systems designed for repeated use).

Please review your use of this code and implement quality measures to decrease appeals and increase timely claim payment. References:

MLN Matters SE1105 – Medicare Drug Screening Testing Medically Unlikely Edits


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