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Drug Screen Testing - Professional
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Reimbursement policy for presumptive and definitive drug screen testing for professional providers and independent clinical laboratories, describing when separate reimbursement is allowed or excluded and associated coding/bundling rules.
No material clinical or coverage changes in this revision.
Coverage and Reimbursement Rules
Coverage criteria
Reimbursement rules for presumptive and definitive drug testing and exclusions:
When Testing Is Covered
Presumptive and definitive drug testing when properly ordered and documented for monitoring or diagnostic purposes.
Covered when properly ordered and documented for monitoring or diagnostic purposes:
Codes and Coding Guidance
| G0480-G0483 | HCPCS definitive drug testing 'per day' codes referenced in policy |
| G0659 | Historically referenced definitive code with bundling guidance when reported with G0480-G0483 |
| 80305-80307 | Presumptive CPT codes referenced in historical updates |
| 80150-80377 | Range of definitive individual drug testing CPT codes mentioned in history/description |
Specimen validity testing performed in conjunction with drug screening is not separately reimbursed. The plan considers specimen validity testing to be included within the CPT and HCPCS code descriptions for both presumptive and definitive drug testing, and modifiers will not override this bundling edit.
Ordering and Documentation Requirements
Order tests and document linkage for confirmatory testing
Tests must be properly ordered and the provider’s documentation and the member’s medical record must reflect that the test was properly ordered; for confirmatory definitive testing, documentation must support that the order was based on the presumptive test result.
- Link confirmatory definitive test orders to the presumptive test result in the medical record.
- Ensure orders are clear, dated, and signed as required by organizational/state rules.
Provider Billing and Authorization Actions
Obtain authorization and document medical necessity
Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and the member’s state of residence; use proper ordering and documentation as specified by the policy.
- Verify any required prior authorization or medical necessity criteria before performing testing.
- Maintain medical record documentation that supports the medical necessity and authorization status for the service.
Follow billing and coding rules to avoid rejection or recovery
Claims may be rejected, denied, or recovered if industry-standard coding/billing guidelines, CPT/HCPCS codes, or current reimbursement policies are not followed; bill with compliant codes and retain supporting medical record documentation.
- Use appropriate CPT, HCPCS, and/or revenue codes that are fully supported in the medical record.
- Be aware the plan may reject or deny claims or recoup payments if submission guidelines are not followed.
Key Definitions
Frequency and Per-Day Limits
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