Part B service-specific review – clinical laboratory presumptive and definitive drug testing

On August 17, 2020, medical review activity resumed, as directed by CMS, with implementation of post-payment service-specific medical record review.

First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted is through medical review of claims. This helps to ensure that Medicare pays for services that are covered, coded correctly, and medically reasonable and necessary. 

High level results and top denial / partial denial reasons are listed below for the post-payment service specific reviews for Presumptive drug testing (CPT80305-80307) and definitive drug testing (HCPCS G0480-G0483) that have been conducted by First Coast. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. 

Clinical laboratory presumptive drug testing (CPT codes 80305-80307) and definitive drug testing (HCPCS code G0480-G0483) (November 2020)

Top full / partial denial reasons:

The most common reasons for denial or partial denials are the following:

• Medical necessity – Documentation submitted did not support the service as medically necessary and reasonable.
  • The documentation submitted did not support a history and/or treatment that warranted testing.
• Insufficient documentation – Insufficient documentation was provided to support the services as billed to Medicare. First Coast Medical Review makes multiple attempts to correct these error types before completion of the review. Below is the following denial reason for insufficient documentation that we were not able to resolve:
  • No response to Additional Documentation Requests (ADRs) – Documentation was not submitted to First Coast in a timely manner in order to support the services billed to Medicare.