ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLABOZO

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

Reimbursement and coding criteria for outpatient presumptive and definitive drug testing and related lab requirements for Blue Cross Blue Shield of Oklahoma members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLABOZO

Change TypeProprietary vendor name replacedclarifications to reimbursement and references

Effective DateNovember 1, 2023

Next Review DateN/A

Key ActionProviders must submit accurate documentation and claims using valid HIPAA-approved code sets; claims may be reviewed and additional documentation requested.

SourceLink

POLICY UPDATE CHANGES

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

Document updated with literature review and reimbursement information revised for clarity; references revised (some added, others removed).

New policy created on 11/1/2022 (initial policy introduction).

1.0policy version

2023-11-01plan effective date

2023-07-17committee approval

>7 classes not reimbursedpanel size limit

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Coverage Criteria for Outpatient Drug Testing

Outpatient drug testing coverage criteria

Presumptive and definitive testing may be reimbursed when specific clinical criteria, frequencies, specimen and ordering/documentation requirements are met.

Presumptive and definitive drug testing for outpatient settings is covered only when the following criteria and documentation requirements are satisfied.

Presumptive testing reimbursable when ANY of the following apply:

Assessment of an individual being treated for chronic non-cancer pain or substance use when clinical evaluation (history/signs/symptoms) suggests use of non‑prescribed medications or illegal substances; includes testing prior to initiating chronic opioid therapy.
Monitoring individuals receiving chronic opioid therapy, with frequency based on risk assessment: low risk — up to 1/year; moderate risk — up to 2/year; high risk — up to 4/year; testing at the visit for individuals with aberrant behavior (lost prescriptions, multiple early refill requests, multiple providers, unauthorized dose escalation, apparent intoxication) meets coverage criteria.
Pregnant individuals at high risk for substance abuse when screening or PDMP information indicates suspicion, as documented in the medical record.
Newborns when there is a history of maternal substance abuse or altered/agitated mental status in the birthing parent.
Candidates for organ transplant with a history of substance abuse to document abstinence prior to transplant.
Individuals with suspected or diagnosed mental illness (e.g., anxiety disorders, schizophrenia, major depressive disorder, mood disorders, suicidal ideation, substance use disorders).
Individuals with attention‑deficit/hyperactivity or disruptive behavior disorders.
Cancer patients receiving opioid pain medication.
Individuals with epilepsy.
Individuals in whom substance abuse is in the differential diagnosis of the presenting condition.

Presumptive testing operational notes

Presumptive drug screening using urine samples may be qualitative, semi‑quantitative, or quantitative and is reimbursable only when clinical criteria above are documented in the medical record.

Definitive (laboratory-based confirmatory) testing reimbursable when ANY of the following are met:

A treating clinician specifically requests laboratory‑based definitive testing and documents the clinical rationale in the medical record.
The presumptive screen result is inconsistent with the individual's history, clinical presentation, or self‑report (for example: negative for prescribed medication, positive for an unprescribed prescription with abuse potential, or positive for an illegal drug).
Definitive testing is required for diagnosing or monitoring individuals with substance use disorder or dependence when accurate and reliable results are necessary for treatment decisions.
A presumptive test does not exist or does not adequately detect the specific drug, metabolite, or synthetic/analog/ designer drugs of interest.
To definitively identify specific drugs within a large drug family or when a definitive drug concentration is needed to guide management (including monitoring individuals on opioid therapy).

Definitive testing frequency limits (by duration of abstinence)

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

Non‑reimbursable situations

Confirmatory/definitive testing panels larger than seven drug classes are not reimbursable.
Blanket or routine standing orders for all patients in a practice are not reimbursable.
Same‑day testing of the same drug/metabolites from two different samples (e.g., both blood and urine) by presumptive or definitive analyses is not reimbursable.
Samples with abnormal specimen validity test results will not be reimbursed.
Drug testing for patients in a facility setting (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.

Specimen types covered

Covered specimen types: urine or oral fluid specimens; blood specimens covered only for patients with anuric chronic renal failure.

Ordering and documentation requirements

Orders must be patient‑specific, include the clinical rationale, and identify each drug or drug class to be tested; reference to a standard order or a 'custom panel' is not acceptable and reflex/automatic testing is not acceptable.
Retroactive orders are not acceptable.
The medical record must document medical necessity for testing.
Requisition and laboratory submission must be signed and include: ordering provider identity, patient identity, specimen type, date/time of collection and receipt, collector identity, and facility/location of collection.
Laboratory results must include laboratory identification, CLIA number, patient and ordering provider identification, collection/receipt dates and times, and complete test results.

Coverage references and recent updates

Reimbursement and coding follow the payer's Clinical Payment and Coding Policy (CPCP020); recent update changed a proprietary vendor name.

Follow Clinical Payment and Coding Policy CPCP020 Drug Testing for coverage, coding, and reimbursement rules that may apply to certain health benefit plans.

Policy update: Proprietary test vendor previously listed as Newstar Medical (RiskViewRX) in reimbursement information has been replaced by CareView360 (recorded in Policy Update History).

Coding and Reimbursement Limits

Covered CPT and Proprietary CodesmixedCovered

80305	Drug testing, definitive, qualitative, each specimen; single drug class method (e.g., GC/MS, LC/MS)
80306	Drug testing, definitive, qualitative, each specimen; two drug classes
80307	Drug testing, definitive, qualitative, each specimen; three or more drug classes
80320-80377	Definitive drug testing CPT range for quantitative and qualitative methods, includes multiple specific analyte/assay codes within this series
0007U	Proprietary/PLA code related to definitive drug testing (specific description per CPT/PLA registry)
0011U	Proprietary/PLA code related to definitive drug testing (specific description per CPT/PLA registry)
0051U	Proprietary/PLA code related to definitive drug testing (specific description per CPT/PLA registry)
0054U	Proprietary/PLA code related to definitive drug testing (specific description per CPT/PLA registry)
0079U	Proprietary/PLA code related to definitive drug testing (specific description per CPT/PLA registry)
0082U	Proprietary/PLA code related to definitive drug testing (specific description per CPT/PLA registry)

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1/2

See external policy for additional codingmixed

No codes listed

Maximum definitive test panel size reimbursed

Maximum definitive test panel size reimbursedConfirmatory/definitive laboratory-based drug testing panels larger than seven drug classes are not reimbursable. Providers should order testing limited to seven or fewer drug class panels unless medical necessity is clearly documented and aligns with exceptions outlined in the policy.

Provider Submission, Documentation, and Related Actions

Documentation Required

Submit accurate documentation and use valid HIPAA code sets

Providers must submit accurate documentation of services performed and file claims using valid HIPAA‑approved code sets. Claims are subject to code edit protocols and review (including benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic); upon request providers may be asked to submit additional documentation.

Use valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD-10, NDC) and follow industry coding guidelines.
Claims are subject to code edit protocols and may be reviewed; provide additional documentation when requested.

Note

See Clinical Payment and Coding Policy CPCP020 (Drug Testing)

Refer to the payer's Clinical Payment and Coding Policy CPCP020 (Drug Testing) for applicable coverage, coding, and reimbursement rules that may apply to certain health benefit plans.

CPCP020 contains detailed coding and payment guidance for drug testing services referenced by this policy.

Definitions and Related Terms

Plan documents

DefinitionPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

GovernanceIf a conflict exists between a CPCP and a plan document, the plan document will govern; if a conflict exists between a CPCP and a provider contract, the provider contract will govern.

Provider actionProviders should review applicable plan documents to determine eligible coverage as not all lab management requirements apply to every product.

Specimen validity testing

Included testsSpecimen 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.

Examples