ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLABO7O

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

Reimbursement and coding criteria for presumptive and definitive (confirmatory) drug testing in the outpatient setting for Blue Cross Blue Shield of New Mexico members; describes covered situations, documentation and laboratory requirements, and billing restrictions. Affects outpatient providers, ordering clinicians, and laboratories submitting urine/oral fluid/blood drug testing claims.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLABO7O

Change TypeCode additions, removals of routine screening applicability, clarifying and exclusion language

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit a signed, patient-specific written order listing each drug or drug class to be tested; retroactive orders are not acceptable.

SourceLink

POLICY UPDATE CHANGES

Added code 0587U effective 10/01/2025.

Added codes 0517U, 0518U, 0519U, 0520U.

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

Under Presumptive drug screening using urine samples, removed certain phrases including 'or substance abuse or dependence' and 'at the following frequencies' from 1a.

Added a general exclusion: in all other situations not addressed above, presumptive and definitive drug screening are not reimbursable.

Proprietary test from Newstar Medical (RiskViewRX) was replaced by CareView360.

up to 4definitive presumptive tests/yr (high risk)

up to 7

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When Outpatient Drug Testing Is Reimbursable

inv-01: Coverage criteria for outpatient drug testing

Covered when ALL of the following documented clinical situations and limits are met:

ALL of the following

ANY of the following
- Assessment related to chronic non-cancer pain: Prior to initiating chronic opioid therapy to determine exposure to controlled substances
- Monitoring of individuals on chronic opioid therapy with frequency based on risk: low risk up to once per year, moderate risk up to twice per year, high risk up to four times per year
- Testing for aberrant behavior at time of visit (e.g., lost prescriptions, multiple early refill requests, multiple providers, apparent intoxication)
- Newborns when there is history of maternal substance use or altered birthing parent mental status
- Pregnant individuals at high risk as indicated by screening questions or PDMP information
- Organ transplant candidates with history of substance abuse to demonstrate abstinence prior to transplant
- Individuals with suspected or diagnosed mental illness, ADHD/disruptive behavior disorders, epilepsy, or cancer patients on opioid therapy
- Management/monitoring of individuals in substance abuse treatment per documented schedule after baseline

ALL of the following

ANY of the following
- Presumptive screen result is inconsistent with the individual's history, clinical presentation, or self-report
- Definitive results are required for diagnosing or monitoring substance use disorder or dependence when accurate/reliable results guide treatment decisions
- A presumptive test does not exist or does not adequately detect the specific drug or metabolite
- Need to definitively identify specific drugs within a large drug family or to obtain a definitive concentration required for management

ALL of the following

0–30 consecutive days abstinence: random definitive testing not to exceed once per week
31–90 consecutive days abstinence: random definitive testing 1–3 per month (no more than 3 definitive tests in one month)
>90 consecutive days abstinence: definitive testing 1–3 tests every three months (no more than 3 definitive tests in a 3‑month period)

ALL of the following

Only urine or oral fluid specimens are covered except blood specimens are covered for patients with anuric chronic renal failure
Specimen validity testing (e.g., urine specific gravity, creatinine, pH, oxidant level, genetic identity) is included in the base service and will not be separately reimbursed

ALL of the following

ANY of the following
- Same‑day testing of the same drug/metabolites from two different samples (e.g., blood and urine)
- Blanket or routine standing orders for all patients in a physician's practice
- Drug testing for patients in facility settings billed separately from the facility fee
- Samples with abnormal validity test results
- More than one presumptive test result per individual per date of service regardless of number of billing providers

inv-02: Coverage and reimbursement criteria (summary of documented revisions)

Summary of documented reimbursement and policy edits — highlights and new exclusion:

ALL of the following

Testing performed solely as a component of a routine physical/medical examination or as a routine component of a behavioral health assessment is not applicable for reimbursement under this policy

ALL of the following

Removed phrases from presumptive urine screening section (e.g., 'or substance abuse or dependence' and specified frequency language in 1a); consult policy for remaining indicated uses

ALL of the following

In all other situations not addressed above, presumptive drug screening and definitive drug testing are not reimbursable

ALL of the following

Procedure Codes and Test Code Updates

Procedure code guidancemixed

Policy lists procedure codes but notes list is not all-encompassing and inclusion does not guarantee coverage.

New/updated laboratory test codesCPT

0587U	Code added effective 10/01/2025 (document notes addition).
0517U	Code added in policy revisions.
0518U	Code added in policy revisions.
0519U	Code added in policy revisions.
0520U	Code added in policy revisions.

Definitive testing drug class limit

Definitive testing drug class limitConfirmatory/definitive laboratory-based qualitative or quantitative testing is reimbursable for up to seven drug classes; when laboratory-based definitive testing is requested for more than seven drug classes, testing is not reimbursable.

Action for labs requesting >7 classesRequests for definitive testing that specify more than seven drug classes will not be reimbursed.

Documentation requirementLaboratory-based definitive testing must be specifically requested and the rationale documented by the individual’s treating physician to be eligible for reimbursement.

Proprietary test exclusionConfirmatory/definitive testing using proprietary tests (e.g., CareView360) is not reimbursable.

Order, Documentation, and Billing Requirements

Documentation Required

Order and requisition requirements — signed, patient-specific orders listing each drug/drug class and panel testing limits

Orders for urine drug testing must be patient-specific, signed and dated by the ordering health care professional, and include the clinical rationale or medical necessity for the test requested. Panel testing is restricted to panels published in the current CPT manual. Retroactive orders are not acceptable.

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; retroactive orders are not acceptable.
Panel testing limited to panels published in the current CPT manual.

Documentation Required

Order and requisition requirements — required requisition content and specimen documentation

Laboratories submitting urine drug testing claims must retain a signed, valid requisition that clearly specifies the tests ordered and includes complete documentation of specimen collection and handling. Reference to a standard order, a generic "custom panel," or automatic/reflex testing is not acceptable — each requisition must list the specific drugs or drug classes to be tested. Requisitions must include patient identifiers, ordering provider identity and signature, collection details, and chain-of-custody information as applicable.

Scope, Exclusions, and Key Term Definitions

Forensic/mandated or employment-related testing

Excluded forensic/mandated testingThis policy does not address state- or federally-regulated and legally mandated drug testing (e.g., court-ordered or forensic examinations).

Employment-related testingNon-forensic testing for commercial driver licensing or other job-related testing (prerequisite for employment or continuation of employment) is excluded from this policy.

Urgent/emergency careDrug testing performed as a component of care rendered in an urgent or emergency situation is not addressed by this policy.

Presumptive vs Definitive testing

Presumptive (screening) testing - scopePresumptive drug screening (urine) may be qualitative, semiquantitative, or quantitative and may be reimbursable for specified clinical indications (e.g., assessment for chronic non-cancer pain, prior to initiating chronic opioid therapy, and routine monitoring with frequency based on risk).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLABO7O

Change TypeCode additions, removals of routine screening applicability, clarifying and exclusion language

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit a signed, patient-specific written order listing each drug or drug class to be tested; retroactive orders are not acceptable.

SourceLink

On This Page

Patient identity: full name and date of birth.
List the specific drugs or drug classes being tested; referencing a standard order or a "custom panel" is not acceptable; reflex (automatic) testing is not acceptable.
Ordering provider identity: full name, credentials, and NPI (preferred).
Legible or appropriate electronic signature with date from the ordering physician (no stamps, photocopies, or "signature on file").
Facility and location where sample was collected (e.g., office, home, hospital, residential treatment center).
Type of sample (urine, saliva, blood, or hair).
Identity of the individual who collected the sample.
Date and time specimen was collected.
Date and time specimen was received by the laboratory.
Complete test results must be available and retained by the laboratory.

Billing Rule

Prior authorization / billing-impacting code updates — recent additions and revisions to CPT/HCPCS-level codes and reimbursement applicability edits

Be aware of recent CPT/HCPCS code additions and reimbursement applicability edits; submitters should verify code applicability and any prior authorization requirements prior to billing. New or revised codes added to this policy (effective dates noted in Policy Update History) may affect reimbursement and require updated billing workflows.

Added codes effective 10/01/2025: 0587U (and other proprietary codes noted in history such as 0517U–0520U).
Providers and billing staff should confirm whether newly added CPT/HCPCS codes require prior authorization or have specific reimbursement edits before submitting claims.
Check Policy Update History for effective dates and summary of revisions that may impact coding and reimbursement.