3D leaves

Late last year, National Government Services (NGS), a Medicare Administrative Contractor (MAC), finalized a coverage decision that limits reimbursement for definitive drug testing to no more than 14 drug classes. Are laboratories that continue to perform blanket testing prepared to enhance their workflow to accommodate these changes? Toxicology labs can no longer use this one-size-fits-all mentality for drug testing. The year 2023 is a very turbulent time in the toxicology sector, and to stay ahead of the local coverage determinations (LCDs) coming down the pipe, you must be proactive in accommodating your NGS’s request for a change of laboratory and billing processes.

No toxicology LIS vendor in the country has stayed ahead of the curve quite like Orchard Software. Orchard has implemented NGS-compliant workflows into our newly launched Orchard Enterprise Toxicology suite to ensure our clients can continue to perform and bill such necessary testing. Overdoses are on the rise, reimbursements are down, and it is up to you to ensure that your lab can perform such necessary testing while remaining compliant with your MAC without compromising an efficient workflow or a constant revenue stream.

As part of a new 2023 directive, Centers for Medicare & Medicaid Services (CMS) is asking their MACs to focus payment audits and claim reviews on providers and labs performing definitive drug testing. While CMS targets labs with high denial rates or unusual billing practices, they can audit any lab performing services under the following toxicology codes:

  • G0480
  • G0481
  • G0482
  • G0483

These audits are being conducted as part of the CMS Targeted Probe and Educate (TPE) program, which intends to help providers identify common billing errors and correct them before implementing more substantial actions, such as prepayment reviews or takebacks.

While your laboratory might be lucky enough to be engaged in the TPE program, your lab might instead be subject to an aggressive audit. Is your LIS vendor capable of appropriately capturing the information required to prove medical necessity? These audits generally request documentation for medical necessity on 20 to 40 claims, with red flags rising at the overuse of generic ICD-10 codes. Orchard® Enterprise Toxicology uses medical necessity tools that allow providers to choose a compliant ICD-10 code at order entry, avoiding a denial or triggering an audit after the testing is performed.

Educating your ordering physicians on the changes ahead is nearly as important as finding a LIS vendor to accommodate these ever-changing LCDs. Orchard enterprise suites include many features to force correct and make compliant order entry before the sample reaches your lab and to communicate new policy changes directly from the order entry portal. Reflex testing is the new way of the world in toxicology, and no one does that better than Orchard. Medication consistency, patient history, type of patient (SUD/COT), and frequency are all used to create a personalized reflex for each patient, allowing you to have a tool bag filled with medical necessity evidence. We are here to help you evolve from yet another blow to toxicology reimbursement.