ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB070

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

Reimbursement and coding policy for outpatient presumptive and definitive drug testing (urine, oral fluid, select blood) and associated documentation requirements for Blue Cross Blue Shield of Oklahoma; applies to providers submitting claims under BCBSOK plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB070

Change TypeMaterial edits to applicability, criteria wording, exclusions, and added codes

Effective DateSeptember 5, 2025

Next Review DateN/A

Key ActionSubmit a signed, patient-specific requisition/order listing each specific drug or drug class, with provider identity and dated signature (no retroactive orders).

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 'or substance abuse or dependence' and 'at the following frequencies' from Presumptive drug screening using urine samples 1a.

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 to the policy coding list.

Other edits made for clarity in reimbursement information.

Document updated with literature review; references revised.

up to 4/yrMax presumptive urine monitoring tests for high-risk patients

up to 3/mo

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Max definitive tests for some abstinence windows

7Max reimbursable confirmatory panel size

≥30Procedure codes mentioned

When Testing Is Reimbursable

inv-01: Coverage criteria

When drug testing is reimbursable and related limits/exclusions

ANY of the following

ALL of the following
- Prior to initiating chronic opioid therapy to determine exposure to controlled substances or illicit drugs
- Routine monitoring of individuals receiving prescription opioid therapy with frequency based on risk: low up to 1/year; moderate up to 2/year; high up to 4/year
- Testing at time of visit for individuals with aberrant behavior (e.g., lost prescriptions, early refill requests, apparent intoxication)
ALL of the following
- Pregnant individuals at high risk for substance abuse when suspicion is documented
- Newborns with a history of maternal substance abuse or altered maternal mental status
- Organ transplant candidates with a history of substance abuse to demonstrate abstinence
- Individuals with suspected or diagnosed mental illness (e.g., anxiety, schizophrenia, mood disorders)
- Individuals with ADHD or disruptive behavior disorders
- Cancer patients on opioid pain medication
- Individuals with epilepsy
ALL of the following
- For individuals in substance abuse treatment: 0–90 days abstinence, qualitative testing 1–2 per week
- For individuals in substance abuse treatment: >90 days abstinence, qualitative testing 1–3 per month

ALL of the following

Validity testing is included in the base code and will not be separately reimbursed

ANY of the following

Confirmatory/definitive testing for panels larger than seven drug classes
Proprietary tests (e.g., CareView360) are not reimbursable
Any AMA definitive drug class codes will not be reimbursed
Same-day testing of the same analyte from two different samples (e.g., blood and urine)
Blanket or routine standing orders for all patients in a practice
Samples with abnormal validity tests

ALL of the following

Only urine or oral fluid specimens are covered except blood specimens for patients with anuric chronic renal failure

inv-02: Documentation criteria

Documentation and laboratory reporting requirements

ALL of the following

Medical record must document medical necessity including relevant history, physical exam, and pertinent diagnostic tests or procedures
Each drug or drug class tested must be indicated in the written order and documented in the patient's medical record

ALL of the following

Laboratories must possess a signed, valid requisition specifying the tests ordered and complete results of tests performed
Orders must be patient specific, include rationale for the test, be signed and dated by the ordering clinician; retroactive orders are not acceptable

ALL of the following

inv-03: Coverage and codes

Codes provided and referral to Clinical Payment and Coding Policy CPCP020 for applicability; inclusion does not guarantee coverage.

ALL of the following

The policy lists example procedure codes (not all-inclusive); inclusion of a code does not guarantee it is a covered service or eligible for reimbursement
See Clinical Payment and Coding Policy CPCP020 for additional applicability and guidance

inv-04: Reimbursement exclusions

Reimbursement applicability changes and exclusions

ALL of the following

Presumptive drug screening and definitive drug testing are not reimbursable in any situations not explicitly addressed in this policy

Procedure and Billing Codes

Mentioned procedure codes (not exhaustive)CPT

80305	Urine drug screen, presumptive
80306	Urine drug screen, presumptive, multiple
80307	Urine drug screen, presumptive, multiple
G0480	Definitive drug test, up to 7 drug classes, qualitative/quantitative

Listed drug testing procedure and lab codesmixed

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

1–10 of 22

1/3

Added codesCPT | HCPCS

0517U	Newly added code (as listed in policy update)
0518U	Newly added code (as listed in policy update)
0519U	Newly added code (as listed in policy update)
0520U	Newly added code (as listed in policy update)

inv-08: Definitive test drug-class limit — Reimbursable for up to seven drug classes; panels larger than seven classes are not reimbursable.

Maximum reimbursable definitive panel sizeUp to 7 drug classes; panels larger than seven drug classes are not reimbursable.

Allowed uses for definitive testingReimbursable when requested by treating physician with documented rationale (e.g., discrepant presumptive result, monitoring substance use disorder, opioid therapy monitoring).

Frequency limits by abstinence duration0–30 days: up to 1/week; 31–90 days: 1–3/month (no more than 3 in one month); >90 days: 1–3 every 3 months (no more than 3 in a 3‑month period).

Situations where definitive testing is appropriateWhen presumptive tests are inadequate or unavailable, to identify specific drugs within a large family, or when definitive concentration is required to guide management.

Proprietary tests and oversized panels

What Providers Must Do

Documentation Required

Submit a signed, patient‑specific order/requisition with required elements

Providers must submit a signed, patient-specific requisition/order that lists the specific drugs or drug classes being tested (reference to a standard order or 'custom panel' is not acceptable). Orders must be patient-specific, include the rationale/need for the test, be signed and dated by the ordering clinician, and retroactive orders are not acceptable. Requisition elements must include patient name and date of birth, ordering provider identity (name, credentials, NPI preferred), legible/electronic signature with date (no stamps), facility/location of collection, specimen type, date/time collected, identity of collector, and date/time received in the laboratory.

List specific drugs or drug classes (no 'standard' or 'custom panel' references; no reflex/automatic testing)
Include patient name and DOB
Include ordering provider name, credentials and NPI (preferred)
Legible or electronic signature with date from ordering clinician (no stamps; retro orders not acceptable)
Document facility/location of collection, specimen type, date/time collected, identity of collector, and date/time received by lab
Order must state rationale/need for the test

Definitions and Notes

inv-13: Presumptive drug screening — definition entry

DefinitionPresumptive drug screening: Initial qualitative, semi-quantitative or quantitative screening tests (commonly urine or oral fluid) used to detect presence of drugs or drug classes; used for assessment, monitoring, or screening purposes.

Coverage contextReimbursement applies only when criteria in the policy are met; certain uses (forensic, employment, emergency) are excluded from this policy.

Specimen typesCovered specimen types are urine and oral fluid; blood may be considered for anuric chronic renal failure patients per policy.

LimitationsRoutine blanket or standing orders, and same‑day duplicate testing of the same analyte from two samples, are non‑reimbursable.

inv-14: Definitive drug testing — definition entry

Definition

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy CPCPLAB070

Change TypeMaterial edits to applicability, criteria wording, exclusions, and added codes

Effective DateSeptember 5, 2025

Next Review DateN/A

Key ActionSubmit a signed, patient-specific requisition/order listing each specific drug or drug class, with provider identity and dated signature (no retroactive orders).

SourceLink

On This Page

Drug testing billed separately in facility settings when included in facility fee

More than one presumptive test result per individual per date of service regardless of billing providers

List of specific drugs or drug classes being tested (reference to a standard order or custom panel is not acceptable; reflex/automatic testing not acceptable)
Patient name and date of birth
Ordering provider identity including full name, credentials, and NPI (preferred)
Legible or appropriate electronic signature with date from ordering physician (not a stamp or photocopy)
Facility and location where sample was collected
Type of sample (urine, saliva, blood, or hair)
Date/time sample was collected
Identity of individual who collected the sample
Date/time sample was received in the laboratory

ALL of the following

Complete identification of testing entity including name, address, and CLIA number
Patient name and date of birth and ordering provider name and NPI
Facility name if applicable, dates collected/received/reported
Complete test results including validity testing if performed

ALL of the following

Confirmatory/definitive testing should be supported by documentation of rationale in the individual's medical record

ANY of the following

Claims are subject to plan documents, provider contract terms, coding policies and code edit protocols; certain uses (forensic, employment, emergency) are excluded from this policy's coverage criteria

ANY of the following

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

Confirmatory/definitive testing using proprietary tests (e.g., CareView360) or panels larger than seven classes is not reimbursable.

Denial Risk

Claims governed by plan documents, contracts, coding policies; certain uses excluded

Claims for drug testing are subject to the member's plan documents, applicable provider contract terms, clinical payment and coding policies, code edit protocols, and claim review processes. The policy does not apply to state/federally mandated forensic testing, employment-related testing (e.g., commercial driver's licensing or job-related testing), or testing as part of urgent/emergency care.

Plan documents and provider contracts govern if conflicts exist
Claims may be subject to code-edit protocols and additional documentation requests
Forensic, legally mandated, employment-related, and urgent/emergency testing are excluded from this policy's coverage criteria

Documentation Required

Refer to CPCP020 Drug Testing for coding/applicability

See Clinical Payment and Coding Policy CPCP020 Drug Testing for additional coding and applicability guidance; CPCP020 may apply for certain health benefit plans.

Reference CPCP020 for further drug testing coding guidance and plan‑specific applicability

Billing Rule

Testing not reimbursable when not explicitly addressed by policy

The policy states that presumptive drug screening and definitive drug screening are not reimbursable in any situations not explicitly addressed in the policy.

If a situation is not explicitly covered by the policy's criteria, presumptive and definitive testing will not be reimbursed

Definitive drug testing: Laboratory‑based confirmatory qualitative or quantitative testing to identify specific drugs or measure concentrations, typically by methods such as GC‑MS or LC‑MS/MS.

When reimbursableReimbursable when specifically requested with documented rationale and when criteria are met (e.g., discrepant presumptive result, monitoring SUD, opioid therapy monitoring).

Frequency and class limitsReimbursable up to 7 drug classes; frequency limits depend on abstinence period (see policy for 0–30, 31–90, and >90 day windows).

Non‑reimbursable usesNot reimbursable for panels >7 classes or when using proprietary tests (e.g., CareView360).

inv-15: Procedure Codes note — Inclusion of a code does not guarantee coverage; not an exhaustive list

Coverage disclaimerInclusion of a procedure code in the policy is not an assurance of coverage or eligibility for reimbursement; see plan documents and coding policies.

Not exhaustiveThe listed codes are examples and do not represent an all‑encompassing code list; providers must follow standard coding guidelines and payer rules.

Related policyRefer to Clinical Payment and Coding Policy CPCP020 for applicability of drug testing codes under certain health benefit plans.

Claim reviewClaims remain subject to contract terms, coding edits, and plan coverage determinations; inclusion in the list does not override these reviews.

inv-16: References / Evidence base — References section lists clinical guidelines and federal guidance informing policy updates

Evidence sourcesPolicy references multiple clinical guidelines and federal documents, including SAMHSA guidance, VA/DoD clinical practice guidelines, and PMTF pain management recommendations.

Federal guidanceCites SAMHSA mandatory guidelines and federal workplace drug testing guidance relevant to specimen types and testing standards.

Professional guidelinesIncludes specialty and professional society resources (e.g., AAN, NICE, ACOG) informing testing indications in specific populations such as pregnancy and epilepsy.

State guidance examplesReferences state program guidance such as OASAS toxicology guidance as part of the evidence base.

Literature reviewsSystematic reviews and guideline appraisals (e.g., Nuckols et al. on opioid prescribing) are included to support policy updates.