Why were drugs of abuse testing chosen as a topic for a comparative billing report (CBR)?
This topic was selected as a CBR because Medicare spending is increasing for urine drug testing (UDT). According to the Medicare Fee-for-Service 2016 Improper Payments Report (aka CERT Report), laboratory testing (which includes urine drug screenings) was one of the Top 20 Service Types with Highest Improper Payment Rates. To review this information, select the following link: Medicare Fee-for-Service 2016 Improper Payments Report.
What is the purpose of this CBR?
The Centers for Medicare & Medicaid Services (CMS) utilizes CBRs as a tool to educate providers about correct billing procedures. CBR201706 was created to inform providers about their billing and payment patterns for Healthcare Common Procedure Coding System (HCPCS) codes G0477 – G0483. For more information about CBRs, please visit our website at this link: Comparative Billing Reports.
How were providers selected to receive CBRs?
To choose recipients for this CBR, we analyzed Medicare Part B claims of providers who billed HCPCS codes G0477 – G0483. Approximately 11,000 providers were identified as potential CBR recipients due to having different billing practices than their peers. If you did not receive a CBR letter and would like to review a sample, please visit our website at CBR201706 Sample CBR.
Did I receive a CBR because of incorrect billing?
Receiving a CBR does not necessarily mean you are billing incorrectly; however, it does indicate that your billing is different than your peers. If you have questions and or concerns about your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.
Is the CBR considered an audit?
The CBR team does not have access to medical records nor do we conduct audits of claims. As such, receipt of a CBR is not considered an audit. If interested in resources that may be helpful with setting up an audit process, please visit our CBR website page at the link titled Self-Audit Help.
What is the purpose of urine drug testing (UDT)?
The purpose of UDT is to identify the presence or absence of drugs in the body and to assist clinicians with determining the best treatment program for a patient.
Are there specific rules for ordering UDT for a patient?
The UDT must be ordered by the treating provider and can be communicated to the testing facility by:
- Written, signed document that is mailed, faxed, or hand delivered
- Telephone call from treating provider’s office
- Electronic mail from treating provider’s office
Per Chapter 15 of the Medicare Benefit Policy Manual, “If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.” For more information, select this link: Medicare Benefit Policy Manual, Chapter 15, Section 80.6.
What is presumptive UDT?
Presumptive UDT uses dipsticks, cups and cards to test for drug classes, and is performed only when results are needed immediately to determine whether drugs are in the body at a certain cutoff level; however, presumptive UDT has limitations and can produce erroneous results because testing does not detect all drugs within a drug class. A positive result may not be a true positive and a negative result may not necessarily mean the body is absent of drugs. Presumptive results can be read by direct observation or by instrumented chemistry analyzers and are reported as either positive or negative. For detailed information, select the following web link: Palmetto GBA LCD L35724.
What is definitive UDT?
Definitive UDT requires highly trained experts who are competent to perform testing using gas and liquid chromatography. These types of tests provide the definitive absence or presence of specific drugs and most illicit substances and the results are most often reported in concentrations such as nanograms per milliliter (ng/ml). Definitive UDT can test for many more substances simultaneously and provides a much faster turn-around time. To see what’s involved in definitive UDT, select this web link: Palmetto GBA LCD L35724.
Can a definitive test be performed if a presumptive test report is negative?
It depends on the circumstances. A definitive test may be medically necessary if the presumptive test is negative for a patient on prescription medication. Also, a definitive test may be required to identify specific drugs if the presumptive screening is positive; however, Medicare would not expect a provider to bill both a presumptive and definitive on every patient or every time the patient is tested. Additionally, the higher level definitive codes would not be billed for most patients. More detailed information can be found at the following web link: First Coast Service Options LCD L36393.
What date of service should I use when filing a UDT claim?
When filing a UDT claim, the date of service should be reported as the date the sample was collected, not the date the test was run.
Which patients will Medicare cover for UDT?
Medicare covers UDT for three patient groups:
- Group A: Patients with signs and symptoms of drug toxicity and/or patients with an unreliable history
- Group B: Patients diagnosed with substance use disorder (SUD)
- Group C: Patients on chronic opioid therapy (COT)
Detailed guidelines can be found at the web link, Palmetto GBA LCD L35724.
Is there certain information I should include to prevent denial of my claims?
You should always contact your MAC if you have questions about a specific claim; however, these conditions should be met and may help to avoid denial of claims:
- The physician ordering UDT must also be the provider treating the patient
- All diagnostic tests ordered must be for treatment of the patient
- Drug testing must be medically necessary and documented in medical records
- Tests are not medically necessary if ordered by any provider other than the treating physician
This information is outlined in the Medicare Learning Network® publication and can be reviewed at this link: Provider Compliance Tips for Laboratory Tests – Other – Urine Drug Screening.
What are some examples of documentation that may be requested for medical review?
Documentation requested for medical review of UDT claims may include:
- Progress notes, clinical evaluations, consultations, hospital records, and office notes
- Reports from laboratories/suppliers
- Any records to assist with conducting review and reaching a conclusion
Where can I find billing guidelines for drugs of abuse?
To find billing guidelines for drugs of abuse testing, please refer to the local coverage determinations (LCDs) and local coverage articles (LCAs) for your region. For your convenience, we have compiled links to these LCDs and LCAs, which can be accessed from our CBR website at the following link: CBR201706 Recommended Links.
What are blanket orders and are they allowed?
Blanket orders are test requests that are identical for all patients in a clinician’s practice and do not have individualized decision making at each visit. Medicare does not cover testing done based on blanket orders. To see more information about blanket orders, select the following web link: CGS Administrators LCD L36029.
Where can I find information on the new codes?
Effective January 1, 2017, CMS implemented four new procedure codes for drugs of abuse testing: CPT® codes 80305, 80306, 80307 and HCPCS code G0659. Additional information on these codes can be found in the CPT® 2017 Professional Edition and the 2017 Professional Edition HCPCS Level II codebooks, which are available from the American Medical Association (AMA) at the web link, AMA Store.
How were providers chosen to receive CBR201706?
For this report, we selected 11,000 referring Medicare providers who filed Part B claims with HCPCS codes G0477 – G0483. Providers receiving CBRs were significantly higher than peers in either their state or the nation on at least one of the measures studied. They were also above the 85th percentile in allowed charges ($5,000), with at least 20 beneficiaries during the period of January 1, 2016 to December 31, 2016.
How was the data obtained for this report?
Claims with the HCPCS codes covered in this CBR were pulled from the Integrated Data Repository (IDR) on June 7, 2017 for Medicare Part B providers who were identified by Referring NPI. The claim lines used in this analysis cover dates of service between January 1, 2016 and December 31, 2016. For more information on the IDR, please visit the link titled, CMS Integrated Data Repository (IDR).
How are the peers defined?
Providers were identified by National Provider Identifier (NPI). The peer groups for comparison with the individual provider are listed below:
- State: All referring Medicare providers practicing in the individual provider’s state indicated as the referring NPI on claims with allowed charges for the procedure codes in this CBR
- National: All referring Medicare providers in the nation indicated as the referring NPI on claims for the procedure codes included in this CBR
What do the comparison outcomes mean?
There are four possible outcomes for the comparisons between the provider and the peer groups:
- Significantly Higher is displayed if the provider’s value is higher than the peer value and the statistical test used confirms significance.
- Higher is displayed if the provider’s value is higher than the peer value, but the statistical test does not confirm significance.
- Does Not Exceed is displayed if the provider’s value is not higher than the peer value.
- N/A (Not applicable) is displayed if the provider does not have sufficient data for comparison.
What does Table 1 show?
Table 1 is a Summary of HCPCS Codes for Drugs of Abuse Testing. The first column lists the Type of testing, the second column lists HCPCS Code and the third column provides the Method/Number of Drug Classes. If you would like to see this example, please select the following link: CBR201706 Sample CBR.
What is the significance of Table 3?
This table gives a summary of the mock provider’s utilization of each procedure code and includes the HCPCS Code, Allowed Charges, Allowed Services, Visit Count, and Beneficiary Count. The provider’s percentages and averages, denoted in Tables 4 through 7, are calculated from the utilization of the procedure codes. To view the mock provider’s sample report, select the following link: CBR201706 Sample CBR.
What is the explanation for Table 4?
Table 4 is the mock provider’s Percentage of Definitive Test using G0483. This mock provider’s percentage is 29 percent, which Does Not Exceed the state’s 44 percent or the nation’s 35 percent. To see the percentages for each state and the nation, please visit the CBR website at CBR201706 Statistical Debriefing.
How are the percentages calculated for definitive tests using G0483 in Table 4?
This measure is calculated as the Number of Definitive Services using G0483 (83) divided by the Total Number of Definitive Test Services (287) for the one year time period, multiplied by 100, resulting in 29 percent.
What is the meaning of Table 5?
Percentage of Services Ordered Too Frequently. Medicare guidelines limit the amount of time between tests of the same type. For this measure, services ordered too frequently is defined as presumptive test services performed within three days of the previous presumptive test and/or definitive test services performed within seven days of the previous definitive test. This provider’s value is 31 percent. The state’s value is 6 percent, and the national value is 3 percent. Based on these results, this provider’s percentage is Significantly Higher than the state and national peer groups. To view results for each state and the nation, select the following link: CBR201706 Statistical Debriefing.
How is the provider’s percentage calculated in Table 5?
This percentage is calculated as the Number of Services Ordered Too Frequently (134) divided by the Total Number of Services (426), and then multiplied by 100, resulting in approximately 31 percent. To see this mock provider’s example, select this link: CBR201706 Sample CBR.
What is the analysis for Table 6?
Table 6 is the mock provider’s Average Services per Beneficiary. This value is calculated to identify potential overutilization of these services. In this example, the provider’s value is 2.84. The state’s value is 2.88 and the national value is 3.22. This provider’s value Does Not Exceed that of the state or national peer groups. The results for each state and the nation can be viewed at the following link: CBR201706 Statistical Debriefing.
How are the average services per beneficiary calculated in Table 6?
Our formula takes the Total Number of Services (426) divided by the Total Number of Beneficiaries (150), resulting in an average of 2.84. To see Table 6, select this web link: CBR201706 Sample CBR.
What’s the meaning of Table 7?
Table 7 is the mock provider’s Average Services per Visit. This measure focuses on the number of actual units (or services) that were allowed on a specific date of service for a beneficiary. This measure differs from the previous measure in that it focuses on the single date of service rather than the total number of services for the entire year. In this example, the provider’s average is 2.73. The state’s average is 1.58 and the national value is 1.48. Based on these results, this provider’s average is Significantly Higher than that of the state and also Significantly Higher than the national peer group. For information on each state and the nation, select this link: CBR201706 Statistical Debriefing.
How are the average services per visit calculated in Table 7?
To calculate this measure, the Total Number of Services (426) is divided by the Total Number of Visits (156), giving an average of 2.73. Table 7 can be viewed at the following link: CBR201706 Sample CBR.