CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB070

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

Defines Blue Cross Blue Shield Oklahoma's reimbursement and documentation requirements for outpatient presumptive and definitive drug testing (primarily urine/oral fluid) and who/when testing is covered; applies to providers and laboratories submitting claims to BCBS OK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB070

Change TypeNew policy

Effective DateNov 1, 2022

Next Review DateN/A

Key ActionOrder and document patient-specific, signed and dated orders listing each drug or drug class tested; retroactive or blanket orders are not acceptable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 7max definitive drug classes

1-4/yrpresumptive monitoring frequency (low/moderate/high)

codes listedprocedure codes specified

excludednon-reimbursable examples

urine/oral

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Coverage Criteria for Drug Testing

Presumptive and Definitive Drug Testing Criteria

Covered when the following presumptive and definitive drug testing indications and frequency limits are met; documentation and ordering requirements apply.

ALL of the following

ONE of
- Assessment prior to initiating chronic opioid therapy to determine exposure to controlled substances or illicit drugs (must be documented in medical record).
- Routine monitoring of patients receiving prescription opioid therapy for chronic non-cancer pain with frequency based on risk level (see frequency node).
- Testing at time of visit for individuals demonstrating aberrant behavior (e.g., lost prescriptions, multiple early refill requests, opioids from multiple providers, unauthorized dose escalation, apparent intoxication).
- Pregnant individuals at high risk for substance abuse when screening responses or PDMP information indicate suspicion (documented).
- Newborns when there is a history of maternal substance abuse or maternal altered/agitated mental status (documented).
- Organ transplant candidates with a history of substance abuse to demonstrate abstinence prior to transplant (documented).
- Individuals with suspected or diagnosed mental illness (including anxiety, schizophrenia, major depressive disorder, mood disorders, suicidal ideation, substance use disorder).
- Individuals with attention-deficit hyperactivity or disruptive behavior disorders.
- Cancer patients receiving opioid pain medication.
- Individuals with epilepsy.
- Individuals where substance abuse is in the differential diagnosis of the presenting condition (but not as part of a general encounter without abnormal findings).

ALL of the following

Risk-based frequency
- Low-risk patients: up to 1 time per year after initiation of therapy.
- Moderate-risk patients: up to 2 times per year after initiation of therapy.
- High-risk patients: up to 4 times per year after initiation of therapy.

ALL of the following

ANY of the following
- Patients with 0–90 consecutive days of abstinence: qualitative testing 1–2 times per week meets coverage criteria.
- Patients with >90 consecutive days of abstinence: qualitative testing 1–3 times per month meets coverage criteria.

ALL of the following

Definitive testing may be reimbursable for up to seven (7) drug classes when medically necessary, including but not limited to: when a presumptive result conflicts with history or clinical presentation; when required for diagnosis or monitoring of substance use disorder per the frequency limits; for opioid therapy monitoring; when no adequate presumptive test exists; or to identify a specific drug within a drug family.
Definitive testing frequency limits for SUD monitoring (must not exceed these limits): 0–30 days: ≤1/week; 31–90 days: 1–3/month (no more than 3/month); >90 days: 1–3 every 3 months (no more than 3 in a 3-month period).

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Billing Codes and Frequency Limits

Covered CPT and HCPCS CodesmixedCovered

80305	Drug screen presumptive, multiple drug classes; non-automated, each procedure
80306	Drug screen presumptive, multiple drug classes; instrumented chemistry analyzers
80307	Drug screen presumptive, multiple drug classes; confirmatory when performed
80320-80377	Definitive/confirmatory drug testing panels and methods (range of CPT codes for definitive testing)
G0480	Drug testing, definitive, each drug class (when billed G0480-G0483 per policy)
G0481	Drug testing definitive, 1-7 drug classes
G0482	Drug testing definitive, 8-14 drug classes
G0483	Drug testing definitive, 15+ drug classes
G0659	Toxicology testing interpretation and consultation (when applicable)

Covered Proprietary/Lab Developed and Other HCPCS/CPT II CodesmixedCovered

0007U	Drug-specific definitive testing (proprietary)
0011U	Drug-specific definitive testing (proprietary)
0051U	Drug-specific definitive testing (proprietary)
0054U	Drug-specific definitive testing (proprietary)
0082U	Drug-specific definitive testing (proprietary)
0093U	Drug-specific definitive testing (proprietary)
0143U-0150U	Series of proprietary definitive drug testing codes (0143U through 0150U)
0227U	Proprietary/other definitive drug testing code

Max definitive drug classes — present as a single key/value (maximum 7 classes).

Maximum definitive drug classesUp to 7 drug classes

Definitive testing frequency limits for SUD monitoring (0-30 days) — render label and frequency 'up to 1/week'.

Definitive testing frequency (0-30 days)Up to 1/week

Definitive testing frequency limits for SUD monitoring (31-90 days) — render label and frequency '1-3/month (no more than 3/month)'.

Definitive testing frequency (31-90 days)1-3/month (no more than 3/month)

Definitive testing frequency limits for SUD monitoring (>90 days) — render label and frequency '1-3 every 3 months (no more than 3/3 months)'.

Orders, Documentation, and Laboratory Submission Requirements

Documentation Required

Orders and Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for drug testing, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Clinician documentation must be patient-specific and accurately reflect the need for each test ordered. Each drug or drug class being tested must be indicated by the ordering clinician in a written order and documented in the patient's medical record.

Each order must be patient-specific, signed and dated by the ordering health care professional, and include the rationale/need for the test requested.
Panel testing is restricted to panels published in the current CPT manual; reference to a ‘standard order’ or a ‘custom panel’ is not acceptable. Reflex (automatic) testing is not acceptable.
Retroactive orders are not acceptable.

Documentation Required

Laboratory Submission Requirements

Laboratories submitting urine drug testing claims must provide a signed, valid requisition form from the ordering provider specifying the tests being ordered, and complete results of the tests performed. Lab results and requisitions must include full identification and timing details to ensure traceability and compliance.

Definitions and Exclusions

Excluded testing circumstances

Forensic or court-ordered testingState or federally regulated and legally mandated testing (e.g., court-ordered, forensic examinations) is not addressed by this policy

Employment-related testingNon-forensic testing for commercial driver licensing or other job-related testing is excluded

Routine examsTesting as a component of routine physical/medical examination is excluded

Urgent/emergency careTesting as part of care rendered in an urgent/emergency situation is excluded

Routine behavioral health assessmentsRoutine behavioral health component testing is excluded

Specific validity testing

Policy Revision History

2022-11-01Policy creationLatest

Policy created and published as a new policy effective 2022-11-01.