ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB070

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

Defines reimbursement and documentation requirements for presumptive and definitive outpatient drug testing (primarily urine/oral fluid) for Blue Cross Blue Shield of New Mexico members; applies to providers and laboratories submitting claims under BCBSNM products. Not all requirements apply to every product—plan documents govern benefits.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB070

Change TypeReimbursement criteria edits and code additions

Effective DateSep 5, 2025

Next Review DateN/A

Key ActionOrders must be patient-specific, signed and dated by the ordering clinician and the requisition must list specific drugs or drug classes with patient and ordering provider identifiers; retroactive orders are not acceptable.

SourceLink

POLICY UPDATE CHANGES

Removed applicability of testing as a component of routine physical/medical examination and as a routine component of a behavioral health assessment.

Removed phrases 'or substance abuse or dependence' and 'at the following frequencies' from presumptive urine drug screening provision 1a.

Added general statement that in all other situations not addressed, presumptive and definitive drug screening are not reimbursable.

Added CPT category I or III codes 0517U, 0518U, 0519U, 0520U to the coding list.

Other edits made for clarity and literature review references were revised.

up to 4/yrMax presumptive urine screens for high-risk chronic opioid therapy patients

7 classesDefinitive drug testing reimbursable for panels up to

≤3/mo

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Outpatient Drug Testing Coverage Criteria

Outpatient drug testing coverage criteria

Covered when ALL listed conditions below are met for presumptive and/or definitive outpatient drug testing:

Presumptive and definitive outpatient drug testing are reimbursable only when medical record documentation demonstrates medical necessity and the testing scenario matches one of the covered clinical indications below.

Presumptive urine screening reimbursable when ANY of the following apply:

To assess an individual treated for chronic, non‑cancer pain when clinical evaluation (history/signs/symptoms) suggests use of non‑prescribed medications or illegal substances, including: prior to initiating chronic opioid therapy and for routine monitoring of individuals receiving prescription opioid therapy with monitoring frequency based on risk assessment (low risk up to 1/year; moderate risk up to 2/year; high risk up to 4/year).
At the time of visit when clinical escalation, apparent intoxication or other concerning findings warrant testing.
In pregnant individuals at high risk for substance abuse when suspicion is supported by screening questions or PDMP information documented in the medical record.
In newborns when there is a history of maternal substance abuse or agitated/altered mental status in the birthing parent.
In organ transplant candidates with a history of substance abuse to demonstrate abstinence prior to transplant.
In individuals with suspected or diagnosed mental illness (e.g., anxiety disorders, schizophrenia, major depressive disorder, mood disorders, suicidal ideation, substance use disorders).
In individuals with attention‑deficit/hyperactivity and disruptive behavior disorders.
In cancer patients receiving opioid pain medication.
In individuals with epilepsy.
For management and compliance monitoring of individuals in treatment for substance use disorder or dependence with documented frequencies: 0–90 days abstinence qualitative testing 1–2 per week; >90 days qualitative testing 1–3 per month (as specified in the medical record).

Definitive (confirmatory) testing reimbursable when ALL of the following are met:

Laboratory‑based definitive qualitative or quantitative testing is specifically requested and the treating clinician documents the rationale in the medical record.
AND when ANY of the following conditions apply:
- The presumptive drug screen result is inconsistent with the individual's history, clinical presentation, or statement (e.g., negative for prescribed medication, positive for non‑prescribed prescription with abuse potential, or positive for an illegal drug).
- Accurate and reliable results are necessary to diagnose or monitor an individual with substance use disorder or dependence (treatment‑decision necessity).
- Monitoring of individuals on opioid therapy to ensure adherence, inform treatment planning, or detect non‑prescribed opioids.
- A presumptive test does not exist or does not adequately detect the specific drug or metabolite requested (including certain synthetic/analog/designer drugs).

Specimen types covered: only urine or oral fluid specimens are covered except blood specimens are covered for patients with anuric chronic renal failure.

Exclusions (not reimbursable)

State/federally mandated testing, employment‑related (including commercial driver) testing, and urgent/emergency care testing are not addressed or reimbursed under this policy.
Any AMA definitive drug class codes are not reimbursable.
Same‑day testing of the same drug/metabolites from two different samples (e.g., blood and urine) is not reimbursable.
Blanket orders or routine standing orders for all patients in a physician's practice are not reimbursable.
Samples with abnormal specimen validity tests are not reimbursable; specimen validity testing (e.g., specific gravity, creatinine, pH, oxidant level, genetic identity) is included in the base code and not separately reimbursed.

Documentation and order requirements

Medical record must support medical necessity and include the rationale for testing.
Orders must be patient‑specific, signed and dated by the ordering clinician and include the rationale/need for the test; retroactive orders are not acceptable.
Requisition must list the specific drugs or drug classes to be tested (reference to a standard order or 'custom panel' is not acceptable) and include patient identifiers, ordering provider identity and signature, collection location, sample type, collection and receipt timestamps, and collector identity.
Laboratory results must include performing entity, CLIA number, patient identifiers, ordering provider NPI, and complete test results including specimen validity information.

Billing and operational rules

More than one presumptive test result per individual per date of service will not be reimbursed regardless of number of billing providers.
It is not reasonable/necessary to perform point‑of‑care qualitative testing and also order presumptive testing from a reference laboratory on the same specimen; similarly, duplicate presumptive immunoassay testing (provider and reference lab) is not reimbursable.
Confirmatory/definitive testing must be supported by documentation of rationale in the individual's medical record.

Coding and coverage cross-reference

Codes enumerated here may be subject to coverage rules in CPCP020; inclusion in the list does not guarantee reimbursement.

Representative procedure codes provided in the policy as examples and cross‑references — inclusion does not ensure coverage; consult payer plan documents and CPCP020 for applicability.

Example codes listed in the policy: 80305, 80306, 80307, 80320‑80377, selected PLA/unique codes (0007U, 0011U, 0051U, 0054U, 0079U, 0082U, 0093U, 0227U, 0328U, 0517U, 0518U, 0519U, 0520U), and HCPCS G0480‑G0483, G0659.

See Clinical Payment and Coding Policy CPCP020 for cases where additional coverage rules may apply.

Reimbursement criteria changes

Key reimbursement edits made in this update:

Added a general reimbursement restriction: 'In all other situations not addressed above, presumptive drug screening and definitive drug testing are not reimbursable.' (General #6).

Removed applicability of testing as a component of routine physical/medical examination and as a routine component of a behavioral health assessment from the reimbursement statement.

Revised presumptive urine screening provision 1a to remove the phrases 'or substance abuse or dependence' and 'at the following frequencies'—consult the updated presumptive screening criteria for current wording.

Other edits for clarity and literature review/reference updates were made; also added CPT codes 0517U, 0518U, 0519U, 0520U to the code list.

Procedure and Billing Codes

Listed procedure codesmixed

80305-80307, 80320-80377, G0480-G0483, G0659, selected U-codes and PLA codes

Representative presumptive and definitive drug testing and related lab codes (not exhaustive, inclusion not guarantee of coverage).

Procedure/PLA/HCPCS codes mentionedmixed

80305
80306
80307
80320-80377
0007U
0011U
0051U
0054U
0079U
0082U

1–10 of 22

1/3

Added codesCPT

0517U	Newly added code (document lists addition)
0518U	Newly added code (document lists addition)
0519U	Newly added code (document lists addition)
0520U	Newly added code (document lists addition)

inv-07: Definitive testing panel limit

Definitive panel limitConfirmatory/definitive drug testing panels up to seven drug classes are reimbursable; panels larger than seven drug classes are not reimbursable.

Frequency limits tied to abstinence duration0–30 days abstinent: random definitive testing up to 1 per week; 31–90 days: 1–3 per month (no more than 3/month); >90 days: 1–3 tests every 3 months (no more than 3/3 months)

Clinical justification requiredLaboratory-based definitive testing must be specifically requested with documented rationale by the treating physician and meet one of the listed clinical conditions (e.g., discrepant presumptive result, monitoring substance use disorder, monitoring opioid therapy)

Orders, Documentation, and Provider Responsibilities

Documentation Required

Order and requisition must be patient‑specific, signed, and include detailed test and patient identifiers

Orders must be patient-specific, include the rationale/need for the test, and be signed and dated by the ordering health care professional; retroactive orders are not acceptable. Requisition forms must specify the tests ordered and include the list of specific drugs or drug classes being tested, patient name and date of birth, ordering provider identity (name, credentials, NPI preferred) and a legible/signature with date, collection facility/location, specimen type, date/time of collection, identity of the collector, and date/time received by the laboratory.

Orders must be patient specific and include the rationale/need for the test requested.
Orders must be signed and dated by the ordering health care professional; retro orders are not acceptable.
Requisition must list specific drugs or drug classes (reference to a standard order, 'custom panel' or 'reflex' testing is not acceptable).
Requisition must include patient identity, ordering provider identity and signature with date, collection location, sample type, collection date/time, collector identity, and laboratory receipt date/time.

Documentation Required

Definitions, Specimen Validity, and Exclusions

inv-12: Excluded circumstances

Excluded: legally mandated/forensic testingState- or federally regulated and legally mandated drug testing (e.g., court-ordered or forensic examinations) are not addressed or reimbursed under this policy.

Excluded: employment-related testingNon-forensic testing for commercial driver licensing or other job-related testing (pre-employment or continuation of employment) is not addressed or reimbursed.

Excluded: urgent/emergency careDrug testing as a component of care rendered in an urgent or emergency situation is not addressed or reimbursed under this policy.

inv-13: Specimen validity testing

Validity tests included in base codeSpecimen validity testing (e.g., urine specific gravity, urine creatinine, pH, urine oxidant level, genetic identity testing) is included in the base code and will not be separately reimbursed.