Reimbursement Policy Drug Screen Testing
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Defines Amerigroup's reimbursement rules for presumptive and definitive drug testing and specimen validity testing for covered members; applies to providers submitting claims to Amerigroup (Georgia plans shown).
No material clinical or coverage changes in this revision.
Coverage and Reimbursement Rules
Drug screen testing coverage
Covered when ALL of the following are met:
Clinical need to identify/confirm presence of specific substances or refine presumptive test accuracy.
Covered when ANY of the following clinical indications apply:
Coding and Frequency Guidance
| Standard correct coding applies; use CPT, HCPCS, and revenue codes supported by documentation |
Ordering, Documentation, and Billing Actions
Ordering and documentation — provider must order and document tests and confirmatory rationale
Ensure presumptive and definitive drug tests are ordered by the treating provider and that the medical record documents the clinical rationale. For definitive tests performed as confirmatory, documentation must support that the order was based on the presumptive test result; services must also meet authorization and medical necessity guidelines.
- Treating provider must properly order presumptive and definitive drug testing and document orders in the member’s medical record.
- When definitive testing is confirmatory, documentation must show the order was based on the presumptive test result.
- Services must meet applicable authorization and medical necessity requirements and be supported by CPT/HCPCS/revenue codes in the medical record.
Key Definitions
Order and Documentation Requirements
Treating provider must order confirmatory testing; follow same‑day limits
The treating provider must place the order for testing; definitive confirmatory testing performed by an independent clinical laboratory on the same date as presumptive testing is only separately reimbursable for 1–7 drug classes — eight or more drug classes require a subsequent order and will not be separately reimbursed when done the same date as presumptive testing.
- Definitive testing performed by an independent clinical laboratory (POS 81) on the same date as presumptive testing: separate reimbursement allowed for 1–7 drug classes.
- Definitive testing for 8 or more drug classes requires a subsequent order from the treating provider and will not be separately reimbursed if performed on the same date as presumptive testing.
Non-covered Services
The health plan does not allow separate reimbursement for specimen validity testing when used for drug screening. Specimen validity testing (e.g., pH, specific gravity, oxidants, creatinine) is considered bundled into presumptive drug testing CPT and HCPCS code descriptions and is not payable as a separate service. No modifier will override the bundle edit.
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