OIG Calls on CMS to Crack Down on Improper Payment of Definitive Drug and LDL Cholesterol Tests
History tells us that whenever OIG issues a report pointing out a pattern of Medicare Part B overpayments for lab tests, labs and physicians that provide those tests should be concerned. In recent weeks, the agency published not one but a pair of such reports. Here are the details labs need to know about. Improper Payment for Drug Testing Services Payment Rules: Medicare Part B pays for reasonable and necessary drug testing services as part of active treatment for substance use disorders. To code for such services, labs are supposed to use the following procedure codes: Presumptive drug testing: CPT code 80305, 80306, or 80307, depending on the complexity level of the test; and Definitive drug testing: HCPCS G0480, G0481, G0482, G0483, or G0659, based on the number of drug classes, including metabolites, tested. Red Flag: On June 8, OIG issued a new report indicating that in 2019, Part B paid $180 million for drug treatment testing services provided to 274,000 substance use disorders. The fee-for-service improper payment rate for the year was a relatively low 7.3 percent; however, the improper payment rate for the highest-paying drug was 58.9 percent. OIG Findings: So, OIG decided to examine how effectively Medicare […]
- Improper Payment for Drug Testing Services
- Presumptive drug testing: CPT code 80305, 80306, or 80307, depending on the complexity level of the test; and
- Definitive drug testing: HCPCS G0480, G0481, G0482, G0483, or G0659, based on the number of drug classes, including metabolites, tested.
- Clear and consistent requirements or guidance for labs to use in determining the number of drug classes to bill for definitive drug testing services;
- Procedures for identifying or limiting the frequency of drug testing services, e.g., the number of drug tests performed per year for each beneficiary across all jurisdictions; and
- Consistent requirements in Local Coverage Determinations (LCDs) or any procedures for identifying claims for direct-to-definitive drug testing.
- Determine if there’s clinical evidence to support a single, specific reasonable and necessary standard for drug testing services, and if so, establish a National Coverage Determination or develop LCDs with more consistent requirements for drug testing services;
- Clearly indicate in LCDs, Local Coverage Articles, and other instructions how labs should determine the number of drug classes for billing definitive drug testing services;
- Implement a system edit or procedure to identify and limit frequency of drug testing services per beneficiary across all Medicare jurisdictions;
- Consider adding a modifier to claims for definitive drug tests indicating whether a test was based on results obtained from a presumptive drug test; and
- Determine if it’s necessary to conduct postpayment medical review on labs that have been paid for excessive definitive drug tests.
- Improper Payment of LDL Cholesterol Tests and Lipid Panels
- Lipid panels that measure the levels of four lipids in the blood, including total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol, sometimes called “bad cholesterol”; and
- Direct LDL tests that measure the actual level of LDL in the blood.
- Develop oversight mechanisms to identify and prevent improper payments for lipid panel and direct LDL tests to at-risk providers; and
- Educate providers on the billing of direct LDL tests in addition to lipid panels.
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