CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB070

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

Defines BCBSNM reimbursement criteria, documentation, and billing rules for outpatient presumptive and definitive drug testing and specimen validity testing; applies to providers submitting claims to Blue Cross Blue Shield New Mexico and to outpatient settings (with some exceptions).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB070

Change TypeReimbursement wording and reference revisionsproprietary test replacement

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionOrdering clinicians must document medical necessity and include a patient-specific, signed and dated order specifying each drug or drug class requested.

SourceLink

POLICY UPDATE CHANGES

Proprietary test from Newstar Medical (RiskViewRX) in #4 was replaced by CareView360 in reimbursement information.

Reimbursement information revised for clarity and literature review added; references revised with additions and removals.

7max classes reimbursable

1–4/yrpresumptive monitoring freq (low–high)

≤1/wkdefinitive freq (0–30 days)

Noproprietary tests reimbursed

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Nospecimen validity reimbursed separately

3policy updates listed

Coverage Criteria and Limits

Presumptive Testing Coverage

Covered when ALL of the following patient-specific clinical and frequency criteria are met:

Presumptive urine drug screening (qualitative, semi-quantitative or quantitative) is requested

AND the test is for ANY of the following clinical situations:

Assessing an individual being treated for chronic non-cancer pain or substance use when clinical evaluation (history/signs/symptoms) suggests use of non-prescribed or illegal substances
Prior to initiating chronic opioid therapy to determine exposure to controlled substances or illicit drugs
Routine monitoring of individuals receiving prescription opioid therapy with frequency based on risk tier: low up to 1/year, moderate up to 2/year, high up to 4/year
Testing at time of visit for individuals with aberrant behavior (lost prescriptions, early refill requests, multiple providers, unauthorized dose escalation, apparent intoxication)
Pregnant individuals at high risk for substance abuse as documented by screening questions or PDMP data
Newborns when there is a history of maternal substance abuse or altered maternal status
Organ transplant candidates with a history of substance abuse to demonstrate abstinence prior to transplant
Individuals with suspected or diagnosed mental illness, ADHD/disruptive behavior disorders, cancer patients on opioid medication, or individuals with epilepsy when testing informs care
Management and compliance monitoring during substance abuse treatment per documented schedule: for 0–90 days abstinence, 1–2 per week; for >90 days abstinence, 1–3 per month

Request and documentation for presumptive testing is patient-specific and documented in the medical record (see Documentation Requirements block)

Definitive Testing Coverage

Definitive (confirmatory) testing is reimbursable when the treating physician documents rationale and ONE or more of the specified clinical conditions are met, subject to panel size and frequency limits:

Definitive (qualitative or quantitative) testing is specifically requested and rationale is documented by the treating physician

AND any of the following conditions apply:

Presumptive test result is inconsistent with the individual's history, clinical presentation, or statement (e.g., negative for prescribed meds, positive for an unprescribed prescription or illegal drug)
For diagnosis or monitoring of substance use disorder when accurate, reliable results are necessary for treatment decisions
For monitoring individuals on opioid therapy to ensure adherence, guide treatment planning, or detect nonprescribed opioids

Exclusions and Billing Rules

The following tests and billing situations are not reimbursable or are subject to specific billing constraints:

Non-reimbursable tests and situations include:

Definitive testing for panels larger than seven (7) drug classes is not reimbursable
Confirmatory/definitive or presumptive testing using proprietary tests (e.g., CareView360) is not reimbursable
Specimen validity testing (e.g., urine specific gravity, creatinine, pH, oxidant level, genetic identity testing) is included in the base code and will not be separately reimbursed
Any AMA definitive drug class codes will not be reimbursed
Same-day testing of the same drug/metabolite from two different samples (e.g., blood and urine) by presumptive or definitive analyses will not be reimbursed

Documentation Requirements

Required documentation and reporting for test order validity and reimbursement:

A signed, valid requisition from the ordering provider specifying the tests being ordered is required

Requisition must list specific drugs or drug classes being tested; reference to a standard order, 'custom panel' or reflex/automatic testing is not acceptable

Ordering provider identity must be included: full name, credentials, and NPI number (preferred), with a legible/electronic signature dated by the ordering physician (not a stamp or photocopy)

Requisition must include collection facility/location, specimen type, date/time collected, identity of the individual who collected the sample, and date/time received in the laboratory

Lab results must include performing entity identification (name, address, CLIA number), patient identifiers, ordering provider name and NPI, facility name if applicable, sample collection and receipt dates, report date, and complete test results including validity testing if performed

References and Policy Updates

History of policy updates and supporting references informing coverage determinations:

Policy update history: 11/1/2022 new policy; 7/17/2023 reimbursement information updated to replace a proprietary test (RiskViewRX) with CareView360; 8/15/2023 literature review added and references revised

References cited include clinical practice and guidance documents and peer-reviewed literature (e.g., AACC, ASAM, CDC, SAMHSA, FDA and others) used to inform clinical context and appropriate use of outpatient drug testing

Procedure Codes and Coding Limits

Procedure codes caveatmixed

Procedure code list is not an all-encompassing code list. Inclusion of a code does not guarantee it is a covered service or eligible for reimbursement.

Definitive testing panel size

Maximum reimbursable definitive panel sizeUp to 7 drug classes; panels larger than 7 drug classes are not reimbursable.

When limit appliesApplies when laboratory-based definitive/confirmatory testing is specifically requested and rationale is documented by the treating physician.

Related exclusionConfirmatory testing for panels >7 drug classes is explicitly not reimbursable.

Provider Responsibilities and Billing Instructions

Documentation Required

Order and documentation requirements — patient‑specific signed order and full reporting

Ordering clinicians must document medical necessity and indicate each drug or drug class being tested in a patient-specific, signed and dated order. The requisition must include patient identity, ordering provider identity and a dated, legible signature, collection location, specimen type, date/time collected, identity of the collector, and date/time received by the laboratory. Lab results must identify the performing entity (including CLIA number) and include patient identifiers, ordering provider information, collection/receipt dates, report date, and complete test results.

Each drug or drug class must be specified by the ordering clinician; standard/custom panels or reflex testing are not acceptable.
Requisition must include patient name and DOB; ordering provider name, credentials, and NPI (preferred); and a dated, handwritten or electronic signature (not a stamp).
Include collection location, specimen type, collection date/time, collector identity, and laboratory receipt date/time.
Final lab report must include performing entity identification and CLIA number plus complete test results.

Definitions and Reference Notes

Presumptive drug screening (urine)

DefinitionPresumptive drug screening (urine) — qualitative, semi-quantitative or quantitative urine tests used to assess exposure to controlled substances or illicit drugs and for routine monitoring of individuals on opioid therapy.

When reimbursableReimbursable when used to assess individuals treated for chronic non-cancer pain or substance use if clinical evaluation suggests use of non-prescribed/illegal substances; prior to initiating chronic opioid therapy; routine monitoring based on risk tier; high-risk pregnant individuals; newborns with maternal history of substance use; organ transplant candidates with substance abuse history.

Monitoring frequency (opioid therapy)Low risk: up to 1/year; Moderate risk: up to 2/year; High risk: up to 4/year.

Definitive drug testing (confirmatory testing)

DefinitionDefinitive (confirmatory) drug testing — laboratory-based qualitative or quantitative testing to definitively identify drugs/metabolites or measure concentrations for clinical management.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB070

Change TypeReimbursement wording and reference revisionsproprietary test replacement

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionOrdering clinicians must document medical necessity and include a patient-specific, signed and dated order specifying each drug or drug class requested.

SourceLink

On This Page

When no adequate presumptive test exists or presumptive testing does not detect the specific drug or metabolite (including specific drugs within large families or synthetic/analog drugs)

To definitively identify specific drugs within a large family or when a definitive concentration is needed to guide management

Limits

Panel size: definitive testing panels of more than seven (7) drug classes are not reimbursable (<=7 classes reimbursable)
Frequency limits for individuals with documented abstinence intervals:
- 0–30 consecutive days of abstinence: random definitive testing not to exceed 1 per week
- 31–90 consecutive days of abstinence: random definitive testing 1–3 per month; no more than 3 definitive tests in one month
- >90 consecutive days of abstinence: definitive testing 1–3 per 3-month period; no more than 3 definitive tests in a 3-month period

Blanket or routine standing orders for all patients in a practice are not reimbursable

Samples with abnormal validity tests are not reimbursable

Drug testing for patients in facility settings (inpatient or outpatient) is not separately billable from the facility fee

More than one presumptive test result per individual per date of service regardless of number of billing providers will not be reimbursed

Operational and coding constraint: inclusion of a procedure code on lists does not guarantee coverage; providers must use HIPAA-approved code sets and follow plan/provider contract terms for claims submission

Orders must be patient-specific, include rationale/need for the test, be signed and dated by the ordering health care professional, and panel testing is restricted to panels published in the current CPT manual

Billing Rule

Claims submission responsibilities — accurate coding and contractual compliance

Providers are responsible for submitting accurate claims using HIPAA‑approved code sets and appropriate industry coding guidelines. Claims are subject to coding edits and review against plan documents, provider contract terms, clinical payment and coding policies, and claim‑editing software; additional documentation may be requested.

Use valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, etc.) and follow industry coding guidelines.
Claims may be denied or adjusted per plan documents, provider contracts, coding edits, and clinical policy rules—review member plan documents for coverage eligibility.
Upon request, submit any additional documentation to support the claim.

Note

Reimbursement update — proprietary test replaced and entries clarified

Reimbursement information was updated to replace the proprietary test Newstar Medical (RiskViewRX) with CareView360; reimbursement entries and references were revised for clarity per the policy update history.

Operational reimbursement entry swap: RiskViewRX → CareView360 (7/17/2023).
Policy updated with literature review and revised references (8/15/2023).

When reimbursableReimbursable up to seven drug classes when specifically requested and the treating physician documents the rationale (e.g., discrepant presumptive result, diagnosis/monitoring of substance use disorder, monitoring on opioid therapy, need to detect specific drugs or concentrations).

Frequency limits for abstinence monitoring0–30 days: ≤1/week; 31–90 days: 1–3/month (max 3/month); >90 days: 1–3 per 3 months (max 3/3 months).

Specimen validity testing

DefinitionSpecimen validity testing — analyses such as urine specific gravity, creatinine, pH, oxidant level, genetic identity testing included in the base code.

Reimbursement stanceIncluded in the base code and not separately reimbursed.

ExamplesUrine specific gravity, urine creatinine, pH, urine oxidant level, genetic identity testing (NextGen Precision™ Testing).

References

Reference listPolicy cites clinical guidelines, professional society guidance, and assay information (e.g., AACC, AAFP, AAN, ACOG and others) to inform coverage positions.

PurposeReferences support clinical context, appropriate use of tests, and inform reimbursement and documentation expectations.

Policy updatesPolicy update history documents operational changes (e.g., replacement of a proprietary test in reimbursement information) and revisions to references and literature review.