In order to effectively treat chronic pain, physicians rely on drug testing to monitor prescribed medications and drugs of abuse. Urine Drug Screening tests which provide qualitative or semi-quantitative initial screen or preliminary results may not be reported with a quantitative code, i.e., codes in the Therapeutic Drug Assay or Chemistry Sections of the CPT book.
Initial screening tests may be performed and billed at point of care or at independent / hospital laboratories, but not both. A second screening of the same urine specimen is considered medically unnecessary. It is the responsibility of the ordering physician to coordinate billing of initial screening tests.
Additionally, quantification of all drugs tested for in a urine drug panel, without regard to screening results, is considered medically unnecessary. Confirmation/quantification of any drug should be the result of an initial positive screen for a drug class, or where there is a documented medical necessity in the patient record for the identification/quantification of a specific drug.
The following paragraphs were added to provide clarity to the policy on urine drug testing:
Physicians Manual: Section 13.41.E
Qualitative and semi-quantitative drug screening tests are covered by the MO HealthNet Program. Refer to the CPT book for appropriate procedure codes to reflect testing on single or multiple drug classes. A drug screen test reports what drug classes (e.g., tricyclic antidepressants, phenothiazines, amphetamines, benzodiazepines, barbiturates, cannabinoids, methadone, opiates) are present (qualitative) and may provide an estimate (semi-quantitative) of the concentration. An initial drug screen or preliminary test that yields qualitative or semi-quantitative results must be reported with an appropriate drug testing procedure code categorized as such in the CPT book. Codes in the Therapeutic Drug Assay or Chemistry Sections of the CPT book may not be used to report qualitative or semi-quantitative drug screening and preliminary test results. Physician offices may bill for initial drug screens performed at point of care (e.g., by use of CLIA waived test devices) or independent and/or hospital laboratories may bill for screenings they performed, but both cannot be billed. It shall be the responsibility of the ordering physician to coordinate with the performing laboratory for the billing of drug screen tests.
Providers should not routinely bill for the quantification of drug classes. Providers should only bill for the quantification of a drug class or a confirmatory drug test (i.e., billing procedure codes from the Therapeutic Drug Assay or Chemistry sections of the CPT book) if there is a positive screen for the drug class to be quantified.
MO HealthNet Division
P.O. Box 808001
Kansas City, MO 64180-8001
The participant must put their MO HealthNet number (case number) on the check or money order. They should mail their payment along with the invoice stub for the month for which they are paying. If they do not have the correct invoice stub to send, they must write on the check or money order what month they are paying for. They must not send an old invoice to pay for a current month. Option 2: Participants may have their payment taken directly out of their bank account on the 10th of each month by the MO HealthNet Division to pay for their spend down obligation for the following month. To have their payment automatically taken from their bank account the participant must complete the Spend down Automatic Withdrawal Form. They must allow 30 days for the automatic withdrawal to process. The participants cannot use bills to meet their spend down if they chose to have the payment taken from their bank account each month through automatic withdrawal. If the participant has insufficient funds to cover the automatic withdrawal, they must send either a money order or cashier’s check to cover the insufficient payment.
If the participant changes banks or changes accounts within their bank, they will need to submit a new automatic withdrawal form (https://dss.mo.gov/mhd/participants/pdf/awa-spenddown.pdf) marked “change,” and will need to allow 30 days for this change to take place. Amounts and Submission of Invoices for private pay services delivered when the recipient is not receiving MO HealthNet benefits (not active on Medicaid) to meet Spend Down: The invoice/bills may be submitted by the provider on behalf of the patient or by the patient directly. Home Health services may be billed to the patient at the agencies usual and customary (private pay) rate (for the same service). CDS and Personal Care services authorized by the Department of Health and Senior Services are allowed to meet spend down but must be billed at the state rate (the Medicaid reimbursement rate for the service). Personal care services that are not authorized by the Department of Health and Senior Services but are medically necessary as prescribed by a physician are allowed to be billed at your usual and customary (private pay) rate. However, you must submit the physician’s order for these services along with the invoice/bill that is submitted to FSD. FSD will review each of these cases and consult with DSDS when necessary. Documenting in-home tasks/time: If you are providing personal care to a DSDS in-home or CDS client on a private pay basis at the beginning of the month during the period of time that the client has not met spend down, you do not have to document every task (5 minutes to brush teeth, 20 minutes to help with bathing, etc.). You may bill for the hour(s) of personal care authorized and delivered. Obviously you can only bill for a service that you provided and for the amount of time it takes (in total) to deliver. So if you were providing 2 hours of personal care and during those two hours you provided assistance with bathing, toileting, meal prep, etc. you do not have to list each of the tasks you provided just list that you provided 2 hours of personal care, the date, the worker, etc.
In an effort to help states reduce improper payments for Medicaid health care claims, the Centers for Medicare and Medicaid Services (CMS) issued a final rule to implement section 6411 of the Affordable Care Act.
Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor allowing states to reimburse contractors who assist in the identification and recovery of improper payments. The RAC program has been used in the Medicare program and is now being required for Medicaid. The mission of the RAC program is to reduce improper payments in Medicaid through the efficient detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments.
The State of Missouri, Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC), contracted with Cognosante, LLC, to be the Medicaid Recovery Audit Contractor. Cognosante is also the NPI Enumerator for CMS and has helped more than three million providers nationally obtain NPI numbers.
Cognosante began sending overpayment letters to certain providers last week. The overpayment letters contain information on repayment options, appeal information, and where to go for questions. The telephone number for Cognosante’s Customer Service Center is (855) 667-2212 or you can email questions to MissouriRAC@cognosante.com
