Definitive Urine Drug Tests - HCPCS Codes G0480-G0483

Applicable To: Mercy Care Complete Care, Mercy Care DD, Mercy Care DCS CHP, Mercy Care Long Term Care, Mercy Care ACC-RBHA and Mercy Care Advantage

Based on a recent article from the Office of the Inspector General (OIG), Drug testing is generally used to detect the presence or absence of drugs in patients undergoing treatment for pain management or substance use disorders. Payments for definitive drug testing services increase based on the number of drug classes tested. The Centers for Medicare & Medicaid Services (CMS) identified overpayments for the definitive drug testing service with the highest reimbursement amount (HCPCS code G0483, definitive drug testing for 22 or more drug classes) due to noncompliance with Medicare requirements. In addition, a prior OIG report on drug testing services identified that payments for G0483 were at risk for overpayments.

In accordance with CMS, Mercy Care conducts audits on these codes to validate medical necessity. CMS defines medical necessity as follows:

"Services must be under accepted standards of medical practice and considered to be specific and effective treatment for the patient's condition. The amount, frequency, and duration of the services planned and provided must be reasonable."

Mercy Care's intent is to review these codes for overutilization as well. This not only applies to Mercy Care Advantage, but to all Medicaid Plans as well. Medical records must be substantiated to prove billing codes of G0480-G0483 are warranted. This will be conducted through medical necessity review via medical records.

Please don't hesitate to contact your Mercy Care Network Management Representative with any questions or comments. You can find this Notice and all other provider notices on our Mercy Care website.

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