Skip to content Skip to navigation

Urine drug testing model likely to roll out nationwide

July 20, 2015
by Julie Miller, Editor in Chief
| Reprints

This week, the Centers for Medicare and Medicaid Services (CMS) held a hearing to address reimbursement policies for various lab services, including urine drug testing. Andrea G. Barthwell, MD, FASAM, who manages Two Dreams Treatment Centers and is a consultant to the laboratory industry, provided testimony to CMS.

According to Barthwell, Palmetto, a CMS claims processing contractor overseeing one of the 10 CMS jurisdictions, has adopted a new urine-testing reimbursement model for its region, which she predicts will ultimately become the nationwide standard. The model does not allow for additional reimbursement when an immunoassay test at a lab is used to confirm a test from the point of care.

“What drug treatment programs must be aware of is that the guidance from Palmetto does not allow the use of a presumptive test to confirm a presumptive test,” Barthwell tells Behavioral Healthcare.

For example, if at the point of care, a clinician processes a dipstick type of test and a lab also completes a test to confirm that result, both testing providers cannot bill for that service.

“It’s been written into the regulation now that that would be disallowed,” she says. “We have indications that it’s going to be adopted across the country.”

She believes the Palmetto model is being viewed as guidance that all the other CMS jurisdictions will follow in how they reimburse for urine drug testing. And it’s the lab’s jurisdiction that determines the rules the provider would need to follow. Barthwell advises that treatment centers confirm with their lab partners whether or when the new guidance will be adopted. It's already policy in the Palmetto jurisdiction.

“You are responsible for knowing how to be in compliance with the laws you operate under,” she says.  “For the folks I’m working with, I advise to err on side of caution and act as if this policy is adopted.”

At this point, the regulations can only be enforced for Medicare and Medicaid claims, however, Barthwell cautions that commercial payers tend to ride on the coattails of CMS and adopt the same policies.

“The trend always is that CMS sets the standard and then commercials tend to follow, which is why we pay attention to what CMS is doing,” she says.

Four tiers

In her testimony, Barthwell also recommended that CMS adopt Palmetto’s tiered structure for testing:

  • Tier I permits testing for up to 7 drugs, and prices are determined by individual drug testing codes (CPT/G-codes);
  • Tier II allows testing for 8 to 15 drugs at a flat rate of $180;
  • Tier III permits testing for 16 to 34 drugs for approximately $215;
  • Tier IV allows testing for 35 or more drugs at a capped rate of $250. Adoption of this code would allow a laboratory to report all available information when ordered.  

“Pricing should correlate with the value of the service provided to ensure that clinicians use drug testing appropriately in the treatment of their patients and valuable healthcare dollars are efficiently allocated,” she said at the hearing.

Topics