Medicare Draft LCDs Limiting Testing to 14 Drug Classes–Open for Comments

Six of the seven Medicare Administrative Contractors (MACs) are proposing revisions to their drug testing policies which may impact reimbursement. Five MACS, including CGS Administrators, First Coast, Novitas, Palmetto GBA, and Wisconsin Physician Services, are proposing to combine drug classes and limit testing to no more than 14 drug classes. The sixth MAC, National Government Services, has implemented changes, effective 10/01/2022, not to cover 15 or more drug classes.

Reasons for the proposed changes include creating consistency with other MACs and helping to resolve the risk identified by the Office of Inspector General (OIG) in existing policies. In the June 2021 Report, OIG reported that Medicare contractors did not have clear and consistent requirements to determine the number of drug classes when identifying a procedure code to bill for definitive drug testing services, and without clear guidance, there was a risk that laboratories could bill for a procedure code with a higher reimbursement amount.  

Procedure Code	Number of Drug Class	2022 Medicare Fee Schedule Amount	Coverage Under Draft LCD
G0480	1 – 7	$114.43	Covered
G0481	8 -14	$156.59	Covered
G0482	15 -21	$198.74	Non-Covered
G0483	22 and more	$246.92	Non-Covered

Source: https://www.cms.gov/medicare-coverage-database/search.aspx