ModifiedEmblemHealthPolicy RPC2O210O04

Reimbursement Policy: Drug and Alcohol Testing (Commercial/Medicaid)

Defines coverage, limits, and billing rules for presumptive and definitive drug and alcohol testing for EmblemHealth and ConnectiCare commercial and Medicaid products, and specifies provider, place-of-service, and laboratory requirements. Applies to outpatient routine urine drug testing and related specimen validity testing.

Policy Summary

PayerEmblemHealth

PolicyDrug and Alcohol Testing reimbursement for presumptive and definitive testing (Commercial and Medicaid)

Policy CodePolicy RPC2O210O04

Change TypeMedicaid criteria and frequency limits addedtemplate/number updates and clarifications

Effective DateApr 1, 2020

Next Review DateN/A

Key ActionDocument clinical rationale and ensure testing is physician‑supervised and within annual unit limits when billing.

SourceLink

POLICY UPDATE CHANGES

Updated to include criteria for EH Medicaid Plans.

Reformatted and reorganized policy, transferred content to new template with new Reimbursement Policy Number.

Clarification added to HCPCS descriptions for G0481-G0483.

Clarification added to exclusions section on definitive testing.

New policy to include annual frequency limits of 18 dates of service for Presumptive Drug Testing and 18 dates of service for Definitive Drug Testing.

18Annual limit (Commercial)

6Annual limit (Medicaid)

1Unit per DOS (Commercial)

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CLIA requiredCLIA requirement

POS 11,21,22…81Places of service listed

Coverage Criteria and Limits

Coverage criteria and exclusions

Presumptive and definitive drug testing are covered only when there is clinical suspicion of drug misuse and the testing meets the specific medical necessity and setting requirements below. Annual unit and per‑date‑of‑service limits vary by plan type (Commercial vs Medicaid). Specimen validity testing is considered part of the test and is not separately reimbursable.

ALL of the following

There is suspicion of drug misuse by the individual being tested.
The results of testing will impact treatment planning.
The diagnosis, history, physical examination and/or behavior of the individual being tested support the need for the specific drug testing being requested.
Testing is performed in a physician‑supervised treatment setting.
Presumptive drug testing: not to exceed 1 unit per date of service, up to 18 units per year (12 months) for Commercial plans; for EmblemHealth Medicaid plans, not to exceed 1 unit per date of service, up to 6 units per year (12 months).
Annual limitations apply to Commercial Plans only unless otherwise stated for Medicaid.
Definitive drug testing: not to exceed 1 unit per date of service, up to 18 units per year (12 months) for Commercial plans; Medicaid follows NY State Medicaid guidelines with the Medicaid annual limit of up to 6 units per year (12 months).
Definitive testing allowed when presumptive testing is unavailable for the suspected drug or when presumptive results are inconsistent with the individual’s condition, history, or examination, or when only drug classes inconsistent with presumptive test are being tested.
High‑complexity laboratory drug tests are covered when performed in a CLIA‑CMS certified laboratory; proof of current CLIA accreditation may be requested for payment.
Laboratory reimbursements may be subject to the in‑office laboratory policy.
Specimen validity testing is included in presumptive and definitive drug testing CPT/HCPCS code descriptions and is considered a quality control step of the collection process and is not separately reimbursable.

Codes, Limits, and Billing Rules

Presumptive Drug Testing (CPT)CPTCovered

80305	Drug test(s), presumptive, any number of drug classes; includes sample validation, per date of service
80306	Drug test(s), presumptive, read by instrument-assisted direct optical observation; includes sample validation, per date of service
80307	Drug test(s), presumptive, by instrument chemistry analyzers or chromatography/mass spectrometry; includes sample validation, per date of service

Definitive Drug Testing (HCPCS)HCPCSCovered

G0480	Definitive drug test(s), qualitative or quantitative, 1-7 drug classes, includes specimen validity testing, per day
G0481	Definitive drug test(s), qualitative or quantitative, 8-14 drug classes, includes specimen validity testing, per day (coverage subject to policy)
G0482	Definitive drug test(s), qualitative or quantitative, 15-21 drug classes, includes specimen validity testing, per day (Not Covered)
G0483	Definitive drug test(s), qualitative or quantitative, 22+ drug classes, includes specimen validity testing, per day (Not Covered)
G0659	Definitive drug test(s) performed without stable isotope/internal standards or without method-specific calibration; per drug/metabolite/class, per specimen

Specimen Validity and Urinalysis (CPT)CPT

81000	Urinalysis by dip stick or tablet reagent; non-automated, with microscopy (includes specified constituents)
81001	Urinalysis by dip stick or tablet reagent; automated, with microscopy
81002	Urinalysis non-automated, without microscopy
81003	Urinalysis automated, without microscopy
81005	Urinalysis; qualitative or semi-quantitative, except immunoassays
81025	Urine pregnancy test, by visual color comparison methods

Single-Class Definitive/Single Drug Class Testing (CPT) — EmblemHealth Medicaid onlyCPTCovered

80320	Alcohol biomarkers
80323	Alkaloids, not otherwise specified
80324	Amphetamines; 1 or 2
80325	Amphetamines; 3 or 4
80326	Amphetamines; 5 or more
80335	Antidepressants, tricyclic and other cyclicals; 1 or 2
80336	Antidepressants, tricyclic and other cyclicals; 3-5
80337	Antidepressants, tricyclic and other cyclicals; 6 or more
80345	Barbiturates
80346	Benzodiazepines; 1-12

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Annual unit limits — Commercial up to 18 units/year; EmblemHealth Medicaid up to 6 units/year

Commercial Plans (Annual unit limits)Presumptive: up to 18 units/year; Definitive: up to 18 units/year

EmblemHealth Medicaid (Annual unit limits)Presumptive and Definitive combined: up to 6 units/year

Per date-of-service limitNo more than 1 unit per date of service for presumptive or definitive testing

Annual date-of-service limit — 18 presumptive; 18 definitive.

Annual date-of-service limit18 presumptive dates of service; 18 definitive dates of service (Commercial)

Provider Requirements and Billing Guidance

Documentation Required

Document clinical necessity and follow annual limits

Presumptive and definitive drug testing are covered only when the provider documents that: (1) the results will impact treatment planning; (2) the diagnosis, history, physical examination and/or behavior support the need for the specific test; and (3) testing is performed in a physician‑supervised treatment setting. Annual unit limits apply (Commercial: up to 18 units/year; EmblemHealth Medicaid: up to 6 units/year).

Document clinical suspicion of drug misuse
Explain how results will change treatment
Include diagnosis, history, exam or behavioral findings that justify the test
Confirm testing performed in a physician‑supervised setting
Apply annual unit limits per plan when ordering and billing

Documentation Required

Provide CLIA accreditation proof for high‑complexity tests

For EmblemHealth Medicaid plans, high‑complexity (definitive) laboratory tests must be performed in a CLIA‑certified laboratory; proof of current CLIA accreditation is required for payment and evidence may be requested.

Key Definitions

inv-12: CLIA-accredited

DefinitionClinical Laboratory Improvement Amendments (CLIA) — a national program that regulates laboratories performing testing on patient specimens to ensure accurate and reliable test results

Accreditation requirementHigh-complexity laboratory drug tests must be performed in a CLIA-approved/CLIA-accredited laboratory for coverage/payment

Proof of accreditationProof of current CLIA accreditation may be requested for payment; laboratory reimbursements may be subject to in-office lab policy

inv-13: Definitive Drug Test

DefinitionDefinitive Drug Test — laboratory method to identify presence/absence or quantity of a specific drug or metabolite; may be quantitative, qualitative, or both; often uses chromatography or spectrometry for confirmation

When covered

Policy Summary

PayerEmblemHealth

PolicyDrug and Alcohol Testing reimbursement for presumptive and definitive testing (Commercial and Medicaid)

Policy CodePolicy RPC2O210O04

Change TypeMedicaid criteria and frequency limits addedtemplate/number updates and clarifications

Effective DateApr 1, 2020

Next Review DateN/A

Key ActionDocument clinical rationale and ensure testing is physician‑supervised and within annual unit limits when billing.

SourceLink

On This Page

Obtain and retain current CLIA certification documentation for the performing lab
Provide CLIA proof to payer upon request to support reimbursement

Denial Risk

Follow coding rules or risk denial/recoupment

Claims that do not follow applicable coding/billing guidelines or current reimbursement policies may be denied and/or result in recoupment; providers may request an explanation of how specific coding edits are handled.

Follow AMA CPT, specialty organization, and CMS (NCCI/MUE) coding edits when submitting claims
If a claim is denied or edited, request an explanation of the coding edits from the payer

Billing Rule

Adhere to annual billing frequency limits and updated HCPCS descriptions

When billing, providers must adhere to the policy's annual frequency limits: up to 18 dates of service per year for Presumptive Drug Testing and up to 18 dates of service per year for Definitive Drug Testing; follow clarified HCPCS descriptions (G0481–G0483) when applicable.

Do not exceed 18 dates of service/year for presumptive testing
Do not exceed 18 dates of service/year for definitive testing
Use updated HCPCS descriptions (G0481–G0483) as clarified in the revision history when billing

Covered up to 1 unit per date of service and subject to annual limits when suspicion of misuse exists and criteria (e.g., impact on treatment, clinical support, physician-supervised setting) are met

Role vs presumptiveUsed when drug classes inconsistent with presumptive testing are needed, presumptive results are inconsistent with clinical picture, or presumptive testing is unavailable

inv-14: Presumptive Drug Test

DefinitionPresumptive Drug Test — qualitative screen producing positive or negative results that classify substances as present or absent based on predetermined cutoffs; often point-of-care

Typical useCovered up to 1 unit per date of service and subject to annual limits when suspicion of misuse exists and criteria (impact on treatment, clinical support, physician-supervised setting) are met

CharacteristicsOften performed with dipsticks, cups, cards, cartridges, or instrumented test systems using immuno- or enzyme-assay techniques

inv-15: Specimen Validity Test

DefinitionSpecimen Validity Test — urine testing to confirm specimen integrity and detect adulteration or substitution (may include pH, specific gravity, oxidants, creatinine)

Billing ruleSpecimen validity testing is included in presumptive and definitive CPT/HCPCS code descriptions and is not separately reimbursable; ConnectiCare will deny separately billed specimen validity testing

PurposeConsidered a quality control integral to the collection process and may be required to assure sample validity

inv-16: High-Complexity Test

DefinitionHigh-Complexity Test — confirmatory tests using specific chromatography or spectrometry techniques (e.g., GC-MS, LC-MS) intended to confirm presumptive results

Laboratory requirementShould be performed in a CLIA-accredited laboratory that follows consistent quality control standards; CLIA proof may be required for payment

Coverage noteHigh-complexity definitive tests are considered covered when performed in a CLIA-approved laboratory and coverage criteria are met

inv-17: CLIA

TermCLIA — Clinical Laboratory Improvement Amendments, the federal program regulating laboratories that perform patient specimen testing

PurposeEnsures laboratories meet standards for accurate and reliable test results

Relevance to policyCLIA accreditation is required for performance and payment of high-complexity definitive tests per policy

inv-18: ASAM guidance

SourceAmerican Society of Addiction Medicine (ASAM) — Drug testing as a component of addiction treatment and monitoring programs; Appropriate Use of Drug Testing in Clinical Addiction Medicine (2017)

RoleASAM guidance is cited as a reference supporting appropriate use of drug testing in clinical addiction treatment and monitoring

AccessPolicy references ASAM position statements and white papers as resources for clinical practice and testing appropriateness