CurrentEmpire BluecrossPolicy C-17004

Outpatient Drug Screen Testing Facility

Governs reimbursement for outpatient facility presumptive and definitive drug screen testing for commercial members of Empire Bluecross (Anthem) and outlines coding and documentation expectations for claims.

Policy Summary

PayerEmpire Bluecross

PolicyOutpatient Drug Screen Testing Facility

Policy CodePolicy C-17004

Change TypeNon‑material administrative updates

Effective Date12/11/2023

Next Review Date

Key ActionEnsure provider documentation supports that definitive testing orders are medically necessary and, when confirmatory, based on presumptive test results.

SourceLink

POLICY UPDATE CHANGES

Updated Definitions section and added coding_link to Related Coding section.

Policy language updated for clarity only.

Policy template updated.

C-17004policy identifier

12/11/2023effective date

Presumptive=CPT; Definitive=HCPCScoding stance

G0659example HCPCS

Outpatient Facility Drug Screen Reimbursement Criteria

Outpatient facility drug screen reimbursement

Anthem allows reimbursement for presumptive and definitive outpatient facility drug screen testing except where provider, state, federal or CMS/contract requirements indicate otherwise; certain definitive CPT codes are considered bundled and not separately reimbursable.

Service is billed on an outpatient facility claim

Service is either a presumptive (CPT) or definitive (HCPCS Level II) drug screen test

Reimbursement permitted unless provider, state, federal, or CMS contracts/requirements indicate otherwise

Provider documentation and the member's medical record must support that the test was properly ordered and medically necessary

Definitive testing specifics

Policy Summary

PayerEmpire Bluecross

PolicyOutpatient Drug Screen Testing Facility

Policy CodePolicy C-17004

Change TypeNon‑material administrative updates

Effective Date12/11/2023

Next Review Date

Key ActionEnsure provider documentation supports that definitive testing orders are medically necessary and, when confirmatory, based on presumptive test results.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization, Documentation, and Billing Expectations

Documentation Required

Authorization and documentation expectations

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; provider documentation should reflect that definitive testing orders are properly supported and, when confirmatory, based on presumptive test results.

Document the clinical indication and diagnosis supporting the test order.
Include presumptive test results in the medical record when definitive testing is confirmatory.
Ensure the test order and results are fully supported in the member's medical record and/or office notes for claim submission.
Follow any applicable provider, state, federal or CMS contract requirements that may supersede this policy.

Key Definitions

Presumptive/Qualitative Drug Testing

DefinitionUsed to determine the presence or absence of drugs or drug classes in a urine sample; results expressed as negative or positive or as a numerical result.

Typical useEmployed as an initial screening test to detect drug classes or presence/absence of substances.

Result formatResults reported as negative/positive or numerical; guides whether definitive/confirmatory testing is ordered.

Definitive/Quantitative Drug Testing

DefinitionUsed to identify specific medications, illicit substances and metabolites; reports analytes present or absent typically in concentrations such as ng/ml.

Typical useUsed to detect specific substances not identified by presumptive methods and to refine accuracy of presumptive test results.

Documentation expectationProvider documentation and member medical records should reflect that the test was properly ordered; confirmatory definitive testing should be based on presumptive test results when applicable.

Policy Revision History and Changes

2023-12-11Review approved and effectiveLatest

Updated Definitions section and added coding link to Related Coding section; review approved and effective.

2021-07-23Review approved

Policy language updated for clarity only.

2019-01-26Review approved

Policy language updated.

2017-08-17Initial approval

Initial approval of the policy.

2014-08-17Effective / approval noted

Policy effective date noted (12/14/2017 referenced in history).

OpenPayer

Outpatient Drug Screen Testing Facility

Outpatient Facility Drug Screen Reimbursement Criteria

Coding: Presumptive and Definitive Drug Testing

Authorization, Documentation, and Billing Expectations

Key Definitions

Policy Revision History and Changes