Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug test services (80307, 82542 and 83789) provided on November 8, 2018.
You asked the Plan to pay for the drug test services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records submitted do not support the CPT codes billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 80307 is Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. The CPT Code Manual definition of 82542 is column chromatography, includes mass spectrometry, if performed (eg, HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS-MS, GC/MS, HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen.
The CPT Code Manual definition of 83789 is mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the drug test services. Our reviewer says that CPT code 80307 does not meet criteria for billing or reimbursement consideration. The medical records and lab results provided does not include documentation of a Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography, includes sample validation when performed, per date of service being performed on November 8, 2018.
Our coder also found that CPT code 82542-59 does not meet criteria for billing or reimbursement consideration. CPT code 82542 was submitted to health plan with a 59 modifier, however the medical records provided do not include documentation that CPT 82542 was a service separately identifiable from CPT code G0480 that was performed and paid on the same date of service. Reimbursement for CPT code 82542 is included in the payment for CPT code G0480 for services provided on November 8, 2018.
Our reviewer found CPT code 83789-59 does not meet criteria for billing or reimbursement consideration. CPT code 83789 was submitted to health plan with a 59 modifier, however the medical records provided do not include documentation that CPT 83789 was a service separately identifiable from CPT code G0480 that was performed and paid on the same date of service. Reimbursement for CPT code 83789 is included in the payment for CPT code G0480 for services provided on November 8, 2018. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug test services have not been met. Therefore, we decided that the Plan does not have to pay for drug test services (80307, 82542 and 83789) provided on November 8, 2018.