Clinical Laboratory Fee Schedule (CLFS) – Special Instructions for Specific Test Codes (CPT Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW and G0431QW)

Provider Types Affected

This article is for clinical laboratories billing Medicare Carriers, Fiscal Intermediaries (FIs) or Part A/B Medicare Administrative Contractors (A/B MACs).

Provider Action Needed

This article is based on Change Request (CR) 6852 which provides special instructions for the proper use of Current Procedural Terminology (CPT) Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW, G0431 and G0431QW as of April 1, 2010. Be sure your billing staffs are aware of the changes outlined in this article.

Each year, the Centers for Medicare & Medicaid Services (CMS) hosts an Annual Public Meeting concerning new test codes that have been established by the CPT committee and that will be covered by Medicare and paid based on the CLFS.

During calendar year (CY) 2009, effective for January 1, 2010, two new G codes were established: G0430 and G0431. It had come to CMS’ attention that some providers were incorrectly using CPT Code 80100 and CPT Code 80101. Therefore, CMS created two new G codes to operate in place of and alongside existing CPT Code 80100 and existing CPT Code 80101.

In addition, those clinical laboratories that require a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver had been utilizing CPT Code 80101 QW. In order to ensure that clinical laboratories that require a CLIA certificate of waiver are also billing correctly whether the drug screen test performed is for a single drug class or multiple drug classes, effective April 1, 2010, two additional G codes were established – G0430QW and G0431QW.