Fallout from the opioid crisis or improper coding?

March 7th, 2018 / By Barbara Aubry, RN

I review OIG updates as they are released and I saw something last week that unfortunately, I did not find surprising. Per the OIG report:

“Payments made to providers for specimen validity tests did not comply with Medicare billing requirements. Specifically, Medicare improperly paid 4,480 clinical laboratories and physician offices a total of $66.3 million for specimen validity tests billed in combination with urine drug tests. Centers for Medicare & Medicaid Services (CMS) officials explained that medically necessary tests used to diagnose certain conditions (which include the same tests that can be used to validate urine specimens) that are performed on the same day as a urine drug test for a single beneficiary should be a rare occurrence.

The improper payments occurred because providers did not follow existing Medicare guidance, and CMS’s system edits were not adequate to prevent payment for specimen validity tests billed in combination with urine drug tests. Improper payments decreased but continued to be made during our audit period as Medicare guidance was updated and CMS introduced new automated system edits. Although CMS implemented on April 1, 2016, a system edit designed to identify and prevent these improper payments, we still identified $1.8 million in improper payments from April 1 through December 31, 2016. At this observed rate, these improper payments would total $12.1 million over a 5 year period. By strengthening its system edits and educating providers on properly billing for specimen validity and urine drug tests, CMS could save an estimated $12.1 million over 5 years.

We recommended that CMS (1) direct the Medicare contractors to recover the $66.3 million in identified improper payments and (2) strengthen its system edits to prevent improper payments for specimen validity tests and instruct the Medicare contractors to educate providers on properly billing for specimen validity and urine drug tests, which could result in savings of an estimated $12.1 million over a 5-year period.

CMS concurred with both of our recommendations and provided information on actions that it had taken or planned to take to address our recommendations.”

My take:

I’ve said this before, if you are paid incorrectly for something that should have hit a CCI (or other) edit, or is not medically appropriate, do not assume the OIG and CMS will not discover the error. If specimen validity testing was billed to CMS, expect a request for reimbursement of the incorrectly paid amounts – unless clinical documentation can support the service – and that will likely require appeal.

CMS does not cover “specimen validity tests” in the general population. CMS believes the number of patients where this may be appropriate is relatively small. The “specimen validity service” usually does not impact medical management, e.g. the result is not medically necessary for treatment in the general medical population. In 2018, CMS uses HCPCS code G0480 for drug tests but this code includes “specimen validity testing.” To a certain extent, it is the standard operating quality control procedure for the laboratory to verify that the specimen being tested is indeed urine and not something else.

In the commercial payer world, or for some specific patients whose employers require drug screening for employment purposes, the rules regarding specimen validity testing may be different. It’s a good idea to double check with those payers to be compliant with their requirements.

A word on proper clinical documentation for drug screening tests in non-Medicare patients since there are several coding options based on the number of drugs that can be tested for. A clear documentation requirement is found in the urine drug test policy from BCBS of Oklahoma 2017:

Drugs or drug classes for which screening is performed should only reflect those likely to be present, based on the patient’s medical history or current clinical presentation and without duplication. Each drug or drug class being tested for must be indicated, by the referring clinician, in a written order and so reflected in the patient’s medical record. Additionally, the clinician’s documentation must be patient specific and accurately reflect the need for each test.

Stories are appearing in the media that chronicle exorbitantly expensive drug screening tests being performed unnecessarily on post-operative patients. This is a frightening example of abuse and has been reported to the government.

CPT and HCPCS codes for drug testing have changed in the last few years. Be sure to check the appropriate code in use for the date of service. And, as proper patient management to monitor the use of opioids matures, I expect further coding and documentation requirements and changes.

Stay tuned on this one.

Barbara Aubry is a senior regulatory analyst for 3M Health Information Systems.