September 25, 2015
Calendar Year 2016 Clinical Laboratory Fee Schedule Preliminary Determinations
On Friday, September 25, 2015, CMS posted its preliminary determinations for drug test codes as well as other new and revised test codes for CY 2016. These preliminary decisions come after discussion at the July CMS-CLFS annual meeting as well as the August PAMA workgroup meeting. Laboratories can issue comments once more on the preliminary decisions, with the agency set to finalize its decisions by November.
Drugs of Abuse Testing
CMS has agreed to modify its original proposal on drugs of abuse testing, which called for deleting all current drug testing G codes and creating a single G code for presumptive testing and a single G code for definitive testing. Several NILA members testified and/or submitted comments in opposition to that proposal.
Most stakeholders had instead advocated for having two presumptive codes and creating multiple/tiered definitive codes. While proposals have varied – some stakeholders advocating for linking the codes to CPT codes and others advocating for following tiered stacking and pricing that mirrors the work of Palmetto or tiering with alternate payment formulas, CMS has again issued its own proposal as follows:
Presumptive Testing (Drug Screening)
The agency proposes to delete G-codes G0431 and G0434 and instead split presumptive testing into 3 new G-codes, changing the descriptors for each specific code (please note: NILA members should carefully review the descriptors to ensure they are appropriate):
- Direct optical observation only (dipsticks, cups, cards, cartridges) – CMS proposes to crosswalk to G0434 x 0.5 = $9.90;
- Direct optical observation with scanner – CMS proposes to crosswalk to G0434 = $19.79;
- Instrumented Chemistry Analyzers and other methods (e.g., mass spectrometry) – CMS proposes to crosswalk to G0434 x 3 = $59.37.
The agency proposes to establish four tiered G-codes for definitive tests, proposing rates that are lower than what many stakeholders recommended (please note: NILA members should review descriptors for each tier to ensure they are appropriate):
- 1-7 drug classes – CMS proposes to crosswalk to 82542 x 2 + 5 x 82542 x 0.10 = $61.45;
- 8-14 drug classes – CMS proposes to crosswalk to 82542 x 2 + 12 x 82542 x 0.10 = $78.66;
- 15-34 drug classes – CMS proposes to crosswalk to 82542 x 2 + 32 x 82542 x 0.10 = $127.82;
- 35 or more drug classes – CMS proposes to crosswalk to 82542 x 2 + 48 x 825426 x 0.10 = $167.14.
CMS also proposes to continue not recognizing AMA CPT codes 80300-80377.