Reimbursement Policy Drug Screen Testing
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Defines Highmark BCBS WNY reimbursement rules for presumptive and definitive drug testing for MMC, HARP, CHPlus, and Essential Plan members; governs laboratory billing and documentation requirements for providers submitting claims.
No material clinical or coverage changes in this revision.
Coverage and Reimbursement Criteria
Drug testing reimbursement criteria
Reimbursement rules for presumptive and definitive drug testing and exclusions for specimen validity testing.
When Definitive Drug Testing Is Covered
Clinical drug testing to identify substances or confirm presumptive results
Definitive testing to identify substances or to confirm presumptive results is covered when properly ordered and documented.
Same‑day reimbursement limit
- If definitive testing is performed the same date as presumptive instrumented chemistry analyzer testing by an independent clinical laboratory (POS 81), separate reimbursement is allowed for definitive testing of 1 to 7 drug classes.
- Definitive testing for eight or more drug classes requires a subsequent order from the treating provider and is not separately reimbursable when performed on the same date as presumptive testing.
Coding and Reimbursement Details
| Standard correct coding applies; use CPT, HCPCS, and revenue codes supported in medical record |
Orders, Authorization, and Documentation
Order subsequent provider authorization for definitive testing of ≥8 drug classes
When definitive drug testing involves eight or more drug classes, obtain a subsequent order from the treating provider; such definitive testing will not be separately reimbursed if performed on the same date of service as presumptive testing without that subsequent order.
- Definitive testing for eight or more drug classes requires a subsequent order from the treating provider.
- Separate reimbursement will not be allowed when performed on the same date of service as presumptive testing without the subsequent order.
Document medical necessity, obtain authorization as required, and support all billed codes
Ensure services meet applicable authorization and medical necessity guidelines and that CPT/HCPCS/revenue codes billed are fully supported in the medical record; failure to follow coding/billing or documentation requirements may result in claim rejection, denial, recoupment, or adjustment.
- Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.
- Bill with industry-standard CPT, HCPCS, and/or revenue codes and ensure the medical record/office notes fully support billed services.
- Noncompliance with coding/billing or documentation may lead to claim rejection/denial, payment recovery/recoupment, or reimbursement adjustment.
Definitions
Services and Codes Not Covered
Highmark Blue Cross Blue Shield WNY does not cover separate reimbursement for specimen validity testing when used for drug screening. Specimen validity testing is considered included in presumptive drug testing CPT and HCPCS code descriptions, and modifiers will not override this bundling.
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