CurrentBlue Cross Blue Shield - IllinoisPolicy CPCP020

Drug Testing Clinical Payment and Coding Policy

Defines reimbursement, coding, documentation, and CLIA requirements for presumptive (qualitative) and definitive (quantitative) drug testing for Blue Cross and Blue Shield of Illinois; applies to providers and laboratories submitting claims to the plan.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyDrug Testing Clinical Payment and Coding Policy

Policy CodePolicy CPCP020

Change TypeNo material changes

Effective DateNov 5, 2024

Next Review DateN/A

Key ActionEnsure correct CPT/HCPCS coding, medical record documentation, and appropriately documented orders when submitting claims for presumptive and definitive drug testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

80305-80307Presumptive CPTs

G0480-G0483, G0659Definitive HCPCS/G codes

RequiredCLIA

One per dateDefinitive code limit

IncludedValidity testing

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Coverage Criteria

Coverage criteria for drug testing reimbursement

Reimbursement for drug testing is covered when coding, documentation, orders, and medical necessity requirements are met and in accordance with MED207.154.

ALL of the following

ALL of the following
- A signed and dated written order from the ordering clinician specifying each drug or drug class being tested is required; 'custom' panels are not acceptable and orders must be specific to the patient.
  Reference: Orders must be signed and dated by the ordering health care professional; 'custom' panels are not reimbursable.
- Clinician documentation must support the test ordered and include relevant history, physical examination, diagnostic test/procedure results, and a diagnosis consistent with findings; each drug or drug class must be indicated in the written order and documented in the medical record.
  Insufficient documentation will result in claim denial; independent labs need not obtain records proactively but must provide them upon request.
ALL of the following
- Presumptive/Definitive sequencing
  - Review of presumptive (qualitative) results by the treating physician should occur before definitive (quantitative) testing is ordered and should be reflected in the medical documentation; if definitive testing is ordered without presumptive testing, the documentation must justify medical necessity.
- Quantitative (definitive) testing should be done in accordance with Medical Policy MED207.154; the rationale for each quantitative test must be supported by the ordering clinician's documentation.
ALL of the following
- Claims must contain correct CPT codes for presumptive testing (80305–80307) or HCPCS/G codes for definitive testing (G0480, G0481, G0482, G0483, G0659); a provider may only bill for services the provider performs (pass-through billing of third-party services is not permitted).
- Only one definitive G code (G0480–G0483 or G0659) may be billed per date of service.
ALL of the following
- Specimen validity testing is included in the base code and may not be billed separately; if validity testing is abnormal, subsequent testing of the same sample is not reimbursable.
- Panel testing is restricted to panels published in the current CPT manual; routine, standing, reflex/automatic, protocol-based quantitative panels without individual patient assessment are not reimbursable.
ALL of the following
- Reimbursement is subject to member benefit and eligibility and may be denied if documentation requirements are not met; submitting laboratories should submit claims to the plan in the state of the ordering provider and must provide documentation upon request.

ALL of the following

This policy does not address state- or federally regulated or legally mandated drug testing (for example, court-ordered drug screening or forensic examinations).

Coding and Billing

Presumptive CPT CodesCPTCovered

80305	Presumptive drug screen read by direct optical observation; includes validity testing; once per date of service
80306	Presumptive drug screen read by instrument-assisted direct optical observation; includes validity testing; once per date of service
80307	Presumptive drug test performed by instrumented chemistry analyzers; includes validity testing; once per date of service

Definitive HCPCS/G CodesHCPCSCovered

G0480	Definitive drug test, 1-7 drug classes; includes specimen validity testing; only one definitive G code per date of service
G0481	Definitive drug test, 8-14 drug classes; includes specimen validity testing; only one definitive G code per date of service
G0482	Definitive drug test, 15-21 drug classes; includes specimen validity testing; only one definitive G code per date of service
G0483	Definitive drug test, 22+ drug classes; includes specimen validity testing; only one definitive G code per date of service
G0659	Definitive drug test without method- or drug-specific calibration or matrix-matched QC; qualitative or quantitative; any number of drug classes; only one definitive G code per date of service

Definitive drug class count per code

G0480Definitive drug test, 1-7 drug class(es); includes specimen validity testing; only one definitive G code may be billed per date of service.

G0481Definitive drug test, 8-14 drug class(es); includes specimen validity testing; only one definitive G code may be billed per date of service.

G0482Definitive drug test, 15-21 drug class(es); includes specimen validity testing; only one definitive G code may be billed per date of service.

G0483Definitive drug test, 22 or more drug class(es); includes specimen validity testing; only one definitive G code may be billed per date of service.

Provider Actions & Requirements

Documentation Required

Prior authorization/documentation requirements for drug testing reimbursement

Reimbursement for presumptive CPT codes 80305–80307 and definitive HCPCS/G codes G0480, G0481, G0482, G0483, and G0659 will be considered only when medical record documentation and appropriately documented, signed and dated orders support the test. Providers may only bill for services they perform; pass-through billing for third-party performed services is not permitted. Claims lacking required documentation (including a written order identifying each drug or drug class tested, relevant clinical history, exam, diagnostic results, and a diagnosis) or using non‑reimbursable panels/standing orders will not be reimbursed.

A written, signed and dated order from the ordering clinician must indicate each drug or drug class being tested; 'custom' panels are not reimbursable.
Clinician documentation must support the test and include relevant history, physical exam, diagnostic/procedure results, and a diagnosis consistent with findings.
Panel testing is limited to panels published in the current CPT manual; routine protocol-based quantitative panels, standing orders, reflex/automatic testing, and custom panels are not reimbursable.
If claims are accompanied by medical records that do not meet documentation requirements, they will not be reimbursed.

Definitions and Requirements

Presumptive (qualitative) testing

DefinitionPresumptive (qualitative) testing is initial drug class screening using CPT 80305-80307; tests are read by direct observation or instrument and include specimen validity testing.

Included codesCPT 80305, 80306, 80307 represent presumptive qualitative drug screens.

FrequencyEach presumptive test may be performed only once per date of service.

Billing noteValidity testing is included in the base presumptive code and may not be billed separately.

Definitive (quantitative) testing

Definition and methodsDefinitive testing uses analytic methods able to identify individual drugs (e.g., GC/MS, LC/MS) and may be qualitative or quantitative; includes specimen validity testing.

CodesDefinitive HCPCS/G codes include G0480, G0481, G0482, G0483, and G0659.

Billing limitOnly one definitive G code may be billed per date of service.

Specimen validitySpecimen validity testing is included in the base definitive code and may not be billed separately.

CLIA Certification requirement

RequirementAny provider (facility or individual practitioner) who performs laboratory testing, including urine drug tests, must possess a valid CLIA certificate for the type of testing performed.

Applies toFacilities and individual practitioners performing laboratory drug testing.

DocumentationProviders performing testing must maintain appropriate CLIA certification as a condition of reimbursement.