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May 25, 2023

Targeted Probe and Educate Program to Focus on Laboratory Testing

The CGS Targeted Probe and Educate (TPE) program will begin a review of claims associated with laboratory testing. Coverage guidance is available in the Local Coverage Determination (LCD) policies L36029External website and L33996External website.

Laboratory Testing claims must meet all medically reasonable and necessary requirements outlined in the applicable statute, regulations and manual provisions.

We expect the documentation you submit to include a copy of the following information from each patient’s medical record that is legible and signed:

  1. Beneficiary’s name
  2. Date of service
  3. Signed medical records that establish:
    1. Medical necessity and relevant history
    2. Signed order or intent to order noted in office record
    3. Ordering provider’s assessment of the patient as it relates to the patient’s complaint at that visit including patient history, physical examination, and previous laboratory findings
    4. Results of pertinent tests/procedures
  4. Additionally, for Urine Drug Testing:
    1. Current treatment plan
    2. Prescribed medication(s)
    3. Risk assessment
  5. Copy of any mandatory ABNs
  6. Appropriate signatures
    1. Signature and credentials of person performing the service must meet CMS requirements
    2. Amendments/corrections/delayed entries are properly identified

For additional documentation requirements, please reference:

CPT codes under review will include:

  • G0481 – Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers)
  • G0483 – Drug test(s) definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers)
  • 82306 – Vitamin D, 25 hydroxy

For more information on the TPE program, please reference:

We encourage you to use the myCGS Portal to identify claims selected for review and submit your documentation. For more information, including step-by-step instructions, please reference the myCGS User Manual.

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