Final Determinations for Repricing Definitive Drug Tests

On Monday, November 21, 2016, the Centers for Medicare and Medicaid Services (CMS) published its final determinations for repricing definitive drug test codes (G0480, G0481, G0482, and G0483).

CMS confirmed its preliminary pricing determinations published on September 30, 2016, as follows:

CMS's repricing results in increases of 46.2% for Tier 1 (G0480); 30.0% for Tier 2 (G0481); 22.2% for Tier 3 (G0482); and 17.1% for Tier 4 (G0483).

Although NILA, and others, had asked CMS to increase the prices to the levels recommended by NILA and the PAMA Advisory Panel on July 18, 2016, CMS declined to do so. According to CMS, "No additional data was submitted to support that recommendation."

CMS did add the following clarifying language to the descriptions for codes G0480-G0483 as follows:

"(2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instument variations and mass spectral drift)"

CMS also modified the description for the new code G0659 by adding the following:

"....performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen;"​​​​​

CMS did not make any changes to the preliminary pricing determinations for presumptive drug test CPT codes 80305 (crosswalked to G0477); 80306 (crosswalked to G0478); and 80307 (crosswalked to G0479).

Click here to view CMS's Final Determinations document.