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Policy No: 106

Originally Created: 01/01/2011

Section: Medicine

Last Reviewed: 09/01/2018

Last Revised:  01/01/2019

Approved: 01/17/2019

Effective: 01/01/2019

This policy applies to ASCs, physicians, laboratories, other qualified health care professionals, hospitals and other facilities.

Definitions

Presumptive Testing

A test used to detect the presence of a drug in a urine sample. The test is performed by a provider with Certification of Waiver or a Medical Test Site Accredited License. Findings are reported qualitatively as either positive or negative.

Definitive Testing

Definitive tests are performed in a laboratory or by a provider with Certificate of Registration, Compliance of Accreditation or Medical Test Site Categorized License or Accredited License.  The tests quantify the amount of drug or metabolite present in the urine sample. Definitive tests can be used to confirm the presence of a specific drug identified by a screening test and can identify drugs that cannot be isolated by currently available presumptive testing. Results are reported as specific levels of substances detected in the urine sample.

Current Procedural Terminology (CPT®) 80305 - 80307 - Drug test(s) presumptive, any number of drug classes; any number of devices or procedures (e.g., immunoassay), includes sample validation when performed, per date of service.

CPT 0007U - Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service.

Healthcare Common Procedure Coding System (HCPCS) - G0480, G0481 and G0659 - Drug test(s) definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomer (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase); qualitative or quantitative, all sources, includes specimen validity testing, per day.

Policy Statement

CPT codes 80320-80377 and 83992 are not eligible for reimbursement.

HCPCS codes G0482, G0483 and 0082U are not eligible for reimbursement. Please refer to Medical Policy, Urine Drug Testing for Substance Abuse and Pain Management (Lab 68)

Presumptive Testing

Presumptive drug tests must be reported using procedure codes 80305-80307 or 0007U. Reimbursement for procedure codes 80305-80307 or 0007U is limited to one unit per day. Only one of the four codes may be billed per day.

Definitive Testing

Definitive drug tests must be reported using procedure codes G0480, G0481 or G0659. Reimbursement for procedure codes G0480, G0481 or G0659 is limited to one unit per day. The units used to determine the appropriate code to bill is "drug class."  The number of drug classes tested determines the appropriate code to use.  Each drug class may only be used once per day. Only one of the three codes may be billed per day.

Modifiers

Modifiers 59, XE, XP, XS, XU and 91 should not be reported with procedure codes 80305-80307, 0007U, G0480, G0481 and G0659.  These modifiers will not bypass the edit.

Guidelines

Presumptive codes are eligible for reimbursement when testing is performed in an office, laboratory or facility setting.  These codes are not eligible for reimbursement for chemical dependency facilities.

The definitive tests must be both more sensitive and specific than the initial screen.

Testing performed as described below is not eligible for reimbursement:

  • Testing as required for, or in conjunction with, participation in substance abuse facilities, at higher levels of treatment, (e.g., residential, inpatient, partial hospitalization).  Urine drug presumptive or definitive testing is considered included in the facility reimbursement. 
  • Unbundled tests when using a multi-test kit screening (e.g. strip, dip card, or cassette)
  • Definitive testing as a routine supplement to drug screens, or in lieu of drug screens except when immunoassay testing is not commercially available.
  • Presumptive testing performed in conjunction with definitive  immunoassay testing
  • Standing orders for definitive testing also known as "custom profile"  
  • Testing ordered by or for third parties (such as courts, schools, military or employers) or ordered for the sole purpose of meeting the requirements of a third party
  • Specimen collection and preparation (included in reimbursement for the testing)

Routine billing of specimen validation is not eligible for reimbursement.

Pass through billing is not eligible for reimbursement. Medically necessary definitive testing must be performed by, and billed by, a laboratory participating with our health plan.

The use of non-participating laboratories may subject our members to unnecessary services not ordered by the treating provider, or other unreasonable financial exposure. In such circumstances, we may hold the treating or referring provider financially liable for any services deemed to be not medically necessary or non-reimbursable if the treating or referring provider referred the specimen or member to the non-participating laboratory.

References

American Medical Association, Current Procedural Terminology (CPT®)

Centers for Medicare & Medicaid Services, Correction to the 2017 Alpha-Numeric HCPCS file

Cross References

Non-Reimbursable Services

Urine Drug Testing for Substance Abuse and Pain Management, Medical Policy, Lab 68

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.