CurrentAnthemPolicy C-17004

Outpatient Drug Screen Testing - Facility

This policy governs reimbursement for outpatient facility presumptive (CPT) and definitive (HCPCS Level II) drug screen testing under Anthem commercial plans and outlines billing and documentation requirements for providers.

Policy Summary

PayerAnthem

PolicyOutpatient Drug Screen Testing - Facility

Policy CodePolicy C-17004

Change TypeNo material change

Effective Date01/01/2026

Next Review Date

Key ActionEnsure provider documentation supports that definitive testing was properly ordered and, when confirmatory, ordered based on presumptive test results.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

always bundledpolicy stance on CPT definitive codes

G0659 reimbursedHCPCS definitive reimbursement

01/01/2026effective date

10/01/2025last review

Coverage Criteria

Outpatient drug screen testing reimbursement criteria

Reimbursement allowed for presumptive and definitive drug testing on outpatient facility claims subject to coding rules, documentation, and applicable contracts or laws.

ALL of the following

Presumptive testing
- Presumptive drug screen testing (CPT) is eligible for reimbursement when submitted on an outpatient facility claim, unless provider, state, or federal contracts require otherwise.
Definitive testing
- HCPCS Level II definitive drug testing (e.g., G0659) may be eligible for reimbursement; when G0659 is reported with G0480, G0481, G0482, or G0483, only G0659 will be eligible for reimbursement.
- The health plan considers CPT definitive drug screen testing codes to be always bundled codes and not eligible for reimbursement.

Policy Summary

PayerAnthem

PolicyOutpatient Drug Screen Testing - Facility

Policy CodePolicy C-17004

Change TypeNo material change

Effective Date01/01/2026

Next Review Date

Key ActionEnsure provider documentation supports that definitive testing was properly ordered and, when confirmatory, ordered based on presumptive test results.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Bundling

Presumptive Drug Testing (CPT)CPTCovered

Presumptive (screening) drug tests reported with CPT codes for initial immunoassay/qualitative screens — covered when billed on an outpatient facility claim and medically indicated.

Definitive Drug Testing (HCPCS Level II)HCPCS

G0480	Drug testing, definitive, per procedure, qualitative or quantitative, single drug class method — G0480.
G0481	Drug testing, definitive, per procedure, qualitative or quantitative, multiple drug classes — G0481.
G0482	Drug testing, definitive, per procedure, quantitative, confirmatory, per specimen, per drug — G0482.
G0483	Drug testing, definitive, per procedure, confirmatory, definitive drug test (method specific) — G0483.
G0659	Drug testing, definitive, by mass spectrometry or chromatography, confirmatory (when reported with G0480-G0483 only G0659 eligible for reimbursement).

Bundling rule — CPT definitive drug screen testing codes are considered always bundled and not eligible for reimbursement.

Bundling ruleCPT definitive drug screen testing codes (the CPT group) are considered always bundled and not eligible for separate reimbursement. When HCPCS Level II definitive drug code G0659 is reported with G0480, G0481, G0482, or G0483, only G0659 will be eligible for reimbursement.

Provider Billing & Documentation Requirements

Documentation Required

Document orders and link confirmatory definitive tests to presumptive results

Ensure the medical record and order clearly support that definitive testing was ordered and, when used as a confirmatory test, that the definitive test order was based on the presumptive test result. Reimbursement for definitive testing is allowed only when documentation demonstrates the test was properly ordered and, for confirmatory definitive testing, linked to the presumptive test result.

Include the definitive test order and clinical indication in the member's medical record.
If the definitive test is confirmatory, document the presumptive test result that prompted the definitive test order.
Maintain supporting documentation on the outpatient facility claim to substantiate reimbursement.

Definitions

Presumptive/Qualitative Drug Testing

DefinitionUsed to determine the presence or absence of drugs or drug classes in a urine sample; results expressed as negative or positive or as a numerical result.

PurposeInitial screening to detect possible drug exposure or drug classes prior to confirmatory testing.

Result formatReported as qualitative outcomes (positive/negative) or as numerical values depending on the test method.

Reimbursement notePresumptive (CPT) testing is eligible for reimbursement on outpatient facility claims subject to coding rules and applicable contracts or laws.

Definitive/Quantitative Drug Testing

DefinitionUsed to identify specific medications, illicit substances and metabolites; reports analytes typically in concentrations such as ng/ml.

PurposeProvides definitive identification and quantification of specific substances and can refine accuracy of presumptive test results.

Documentation requirementProvider documentation and the member's medical record must support that the definitive test was properly ordered; if confirmatory, documentation should show it was ordered based on presumptive test results.

Coding noteHCPCS Level II definitive drug testing (e.g., G0659) may be eligible for reimbursement; when billed with G0480-G0483, only G0659 will be reimbursed.