ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB070

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

Reimbursement and coding criteria for outpatient presumptive and definitive drug testing (urine, oral fluid, blood in select cases) for Blue Cross Blue Shield - Oklahoma members; explains when tests are reimbursable, documentation and ordering requirements, and exclusions.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB070

Change TypeAdded U‑codesclarified reimbursement restrictionswording edits

Effective DateOctober 1, 2025

Next Review Date

Key ActionSubmit a signed, patient-specific requisition/order that lists each drug or drug class tested and includes provider identity, signature/date, collection location, sample type, and collection/receipt timestamps; retroactive orders are not acceptable.

SourceLink

POLICY UPDATE CHANGES

Added code 0587U effective 10/01/2025.

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

Edited language in presumptive urine screening criteria to clarify wording and remove specific phrases.

Added general statement: In all other situations not addressed above, presumptive drug screening and definitive drug screening are not reimbursable.

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

up to 7drug classes reimbursable

up to 4high-risk monitoring frequency

1-3

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31-90 days abstinence freq

1-3/3 months>90 days abstinence freq

~100+literature refs

08/01/2025last review date

Coverage Criteria for Drug Testing

Coverage criteria for drug testing

Covered when ALL documentation, ordering, and clinical criteria below are met. Preserve the AND/OR logic as shown.

Providers must submit a signed, patient-specific requisition/order that specifies each drug or drug class being tested, includes provider identity (name, credentials, NPI preferred), signature and date, collection location, sample type, and collection/receipt timestamps; retroactive orders are not acceptable.

Presumptive drug screening (urine)

To assess an individual being 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).
For individuals with aberrant behavior (e.g., lost prescriptions, multiple early refill requests, opioids from multiple providers, unauthorized dose escalation, apparent intoxication) — testing at time of visit meets coverage criteria.
In pregnant individuals at high risk for substance use when suspicion exists based on screening questions or PDMP information, as 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, schizophrenia, major depressive disorder, mood disorders, suicidal ideation, substance use disorders).
In individuals with ADHD or disruptive behavior disorders.
In cancer patients on opioid pain medication.
In individuals with epilepsy.
For management and compliance monitoring of an individual under treatment for substance use disorder or dependence (after baseline at initial evaluation) with frequencies documented in the medical record: 0–90 days abstinence: qualitative testing 1–2 per week; >90 days abstinence: qualitative testing 1–3 per month.
When substance abuse is in the differential diagnosis of the presenting condition.

Definitive/confirmatory testing

ALL of the following
- Presumptive screen result is discordant with medical history, clinical presentation, or patient statement (e.g., negative for prescribed meds, positive for an unprescribed prescription drug, or positive for an illegal drug).
- Needed for diagnosing or monitoring individuals with substance use disorder or dependence when accurate, reliable results are necessary for treatment decisions.
- For monitoring individuals on opioid therapy to ensure adherence to therapy, guide treatment planning, or detect non-prescribed opioids.
- A presumptive test does not exist or does not adequately detect the specific drug or metabolite to be tested (e.g., specific drugs within amphetamines, barbiturates, benzodiazepines, tricyclic antidepressants, opiates/opioids, synthetic/analog or 'designer' drugs).
- To definitively identify specific drugs within a large family of drugs.

Exclusions / Not reimbursed

Any AMA definitive drug class codes are not reimbursable.
Same-day testing of the same drug or metabolites from two different samples (e.g., blood and urine) by presumptive or definitive analyses is not reimbursable.
Blanket or routine standing orders for all patients (non-patient-specific orders) are not reimbursable.
Samples with abnormal specimen validity test results are not reimbursable.
Drug testing for patients in a facility setting (inpatient or outpatient) is not separately billable from the facility fee.
Confirmatory/definitive or presumptive testing using proprietary tests (e.g., CareView360) is not reimbursable.

Reimbursement restrictions and clarifications

Policy updates and clarifications that affect reimbursement and scope.

General: In all other situations not specifically addressed in this policy, presumptive drug screening and definitive drug screening are not reimbursable.

Policy update history: codes 0517U, 0518U, 0519U, 0520U were added in the document updates; code 0587U was added effective 10/01/2025.

Removed applicability statements: prior wording that testing addressed in this policy applied 'as a component of routine physical/medical examination' and 'as a routine component of a behavioral health assessment' were removed from the Reimbursement Information.

Clarification: Proprietary tests and specific AMA definitive drug class codes are explicitly non-reimbursable (see exclusions).

Procedure Codes and Coding Limits

Procedure codes (non-exhaustive)mixed

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

Recently added U-codesHCPCS

0517U	Newly added code listed in policy update history
0518U	Newly added code listed in policy update history
0519U	Newly added code listed in policy update history
0520U	Newly added code listed in policy update history
0587U	Code added effective 10/01/2025

Definitive drug class panel size limit — inv-05

Definitive panel sizeUp to seven drug classes may be reimbursable for laboratory-based definitive/confirmatory testing; panels larger than seven drug classes are not reimbursable.

Clinical rationale requiredDefinitive testing must be specifically requested and the treating physician must document the rationale in the medical record.

When reimbursableReimbursable when presumptive result is discrepant with history/presentation, for SUD diagnosis/monitoring when accurate results are necessary, or when presumptive tests do not detect the specific drug/metabolite.

Specimen types notedCoverage generally for urine or oral fluid; blood specimens covered only for patients with anuric chronic renal failure (see Reimbursement section).

Reimbursement restriction — inv-06

Provider Ordering, Billing, and Claims Requirements

Denial Risk

Claims review and precedence — claims subject to plan documents, provider contract, medical and coding policies; potential need for additional documentation.

Claims are subject to review and are governed by applicable plan documents, provider contracts, medical policies, clinical payment and coding policies, and coding software logic. If a conflict arises between this Clinical Payment and Coding Policy and a member’s plan document, the plan document will govern. If a conflict arises between this policy and a provider contract, the provider contract will govern. Plan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. Blue Cross and Blue Shield of Oklahoma may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case and has full and final discretionary authority for interpretation and application to the extent provided under any applicable plan documents. Providers are responsible for submitting accurate documentation and coding claims according to industry-standard code sets and guidelines (including UB, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI policy manual and edits). Upon request, the provider should submit additional documentation to support the claim.

Claims are also subject to code edit protocols and may be denied or adjusted based on coding edits, lack of medical necessity, incomplete documentation, or noncompliance with provider contract terms.
Providers should ensure claims are coded appropriately and include all required supporting documentation to avoid delays or denials.

Definitions and Exclusions

Excluded testing contexts — inv-10

State/federal mandated or forensic testingThis policy does not address state, federally regulated or legally mandated drug testing, including court-ordered drug screening and forensic examinations.

Employment and CDL testingNon-forensic testing for commercial driver's licensing or other job-related testing (prerequisite for employment or continuation of employment) is excluded.

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

Facility-based billingDrug testing performed in facility settings may not be separately billable from the facility fee (see non-reimbursement rules).

Specimen validity and excluded test types — inv-11

Specimen validity testing inclusion

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB070

Change TypeAdded U‑codesclarified reimbursement restrictionswording edits

Effective DateOctober 1, 2025

Next Review Date

SourceLink

On This Page

To identify drugs when a definitive concentration is needed to guide management.

Frequency limits for random definitive testing (apply as documented): 0–30 consecutive days abstinence: ≤1 per week; 31–90 days abstinence: 1–3 per month (no more than 3 in one month); >90 days abstinence: 1–3 tests every 3 months (no more than 3 in a 3‑month period).

Panels larger than seven drug classes are not reimbursable.

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

General reimbursement restrictionIn all other situations not specifically addressed by this policy, presumptive drug screening and definitive drug screening are not reimbursable.

Not reimbursed examplesAny AMA definitive drug class codes; same-day testing of the same drug/metabolites from two different samples; blanket or routine standing orders for all patients.

Multiple presumptive testsMore than one presumptive test result per individual per date of service will not be reimbursed, regardless of number of billing providers.

Facility billingDrug testing for patients in a facility setting (inpatient or outpatient) is not separately billable from the facility fee.

Prior Authorization

Prior authorization / coding updates — note added/updated proprietary and analyte-specific CPT/HCPCS codes and non-reimbursable clarifications.

Some tests and CPT/HCPCS codes may require prior authorization or are subject to coding updates. Providers and laboratories should verify applicable coverage, precertification, and billing rules prior to performing testing. Where proprietary or analyte‑specific CPT/HCPCS codes are added or updated, providers must bill the precise code(s) that correspond to the ordered and performed test(s). Tests billed with codes that the policy or payer classifies as non‑reimbursable or not covered may be denied. Contact BCBSOK for any questions about code applicability.

Effective 10/01/2025: added CPT/HCPCS code 0587U (and other proprietary codes noted in policy update history) — bill the specific code for the assay performed.
Do not bill relative or lab-defined panels described as 'custom panel' or 'standard order' without listing the specific analytes; reflex or automatic testing must not be ordered or billed without a patient‑specific signed order.
If prior authorization is required by the member’s plan, obtain approval before testing; lack of prior authorization when required may result in denial.

Specimen 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.

Samples with abnormal validitySamples with abnormal validity tests will not be reimbursed when submitted separately.

Proprietary/AMA tests excludedProprietary tests and any AMA definitive drug class codes are not reimbursed per policy.

Same-day duplicate testingSame-day testing of the same drug or metabolites from two different samples (e.g., blood and urine) by presumptive or definitive analyses will not be reimbursed.

CPCP020 — inv-12

Policy referenceSee Clinical Payment and Coding Policy: CPCP020 — Drug Testing for related coding and payment guidance.

RelationshipCPCP020 is referenced as a related clinical payment and coding policy that may apply for certain health benefit plans.

Precedence noteIf conflicts arise between a Clinical Payment and Coding Policy (like CPCP020) and a member’s plan document, the plan document terms govern claims adjudication.