CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Drug Testing Payment Policy – Archive 2

Defines coverage, limitations, exclusions, specimen and ordering rules, and coding/billing guidance for presumptive (qualitative) and definitive (quantitative) drug toxicology testing for Medicaid, Integrity, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDrug Testing Payment Policy – Archive 2

Policy CodePolicy N/A

Change TypeAnnual review; prior CMP replaced 01/01/2023

Effective DateJan 1, 2023

Next Review Date

Key ActionQuantitative testing must be ordered with the specific drug to be confirmed and the order placed by the treating provider at time of order.

SourceLink

POLICY UPDATE CHANGES

03/11/2024 Annual Policy Review Date. No content changes.

01/01/2023 Policy Effective Date - Replacing prior Urine Toxicology Testing Clinical Medical Policy (CMP) effective 06/01/2016 - 12/31/2022

1Unit limit per day per test type

1-22+Definitive code drug-class ranges

3Qualitative CPT codes listed

5Definitive/HCPCS codes listed

Policy summary & scope

This reimbursement policy covers coverage, limitations, exclusions, specimen and ordering rules, and coding/billing guidance for presumptive (qualitative) and definitive (quantitative) drug toxicology testing for Medicaid (excluding EFP), INTEGRITY, and Commercial lines. It documents requirements for immunoassay/presumptive (qualitative) screening and definitive/confirmatory (quantitative) testing, notes that urine is the preferred specimen for broad screening, and includes coding and billing instructions. Policy Effective Date: 01/01/2023; Last Review Date: 03/11/2024.

Coverage criteria and medical necessity

Qualitative (Presumptive) Drug Tests - Coverage Criteria

Qualitative drug tests are covered when ANY of the following are met:

ANY of the following

Member is receiving treatment for chronic pain with prescription opioid or other medication associated with increased risk for misuse or addiction
Member is undergoing treatment for substance use disorder or is otherwise requiring monitoring for use/misuse of controlled or illicit substance(s)
Misuse of prescribed or illicit substances is suspected
Member is beginning a pain management program or substance use disorder treatment program

Quantitative (Definitive/Confirmatory) Tests - Coverage Criteria

Quantitative drug tests are covered when ALL of the following apply (examples include but are not limited to):

ALL of the following

Ordered on an individual basis by a medical provider directly caring for the member at the time of order (no standing/routine orders)
Ordered with an indication of the specific drug being confirmed (not as a comprehensive confirmatory panel)
Performed in a laboratory
Examples of covered indications
- Unexpected positive test inadequately explained by the patient
- Unexpected negative test (suspected medication diversion)

General Medical Necessity Prerequisites

All services must meet medical necessity; Neighborhood may use the following to determine:

ALL of the following

National Coverage Determination (NCD) may apply
Local Coverage Determination (LCD) may apply
Industry accepted criteria such as InterQual may be used
EOHHS recommendations may be used
Neighborhood Clinical Medical Policies (CMP) may be used

Billing codes and code guidance

Presumptive / Qualitative CPT codesCPTCovered

80305	Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g. immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.
80306	Drug test(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures by instrument chemistry analyzers (e.g., utilizing immunoassay, chromatography, and mass spectrometry), includes sample validation when performed, per date of service.
80307	Drug test(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures by instrument chemistry analyzers (e.g., utilizing immunoassay, chromatography, and mass spectrometry), includes sample validation when performed, per date of service.

Definitive / Quantitative CPT/HCPCS codesmixedCovered

G0480	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es).
G0481	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug class(es).
G0482	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es).
G0483	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es).
G0659	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, performed without method or drug-specific calibration or universally recognized internal standards, qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes.

Specimen Validity Testing - billingmixedNot Covered

Urinary specimen validity testing (e.g., pH, specific gravity, creatinine, nitrates, oxidants) used to confirm non-adulteration is considered an internal control process and should not be separately billed.

Urine is the preferred specimen for broad screening because blood is relatively insensitive for many common drugs and saliva has a shorter detection window; quantitative (definitive) tests must be ordered specifically (with the drug to be confirmed) and must be performed in a laboratory.

Billing, documentation, and denial risks

Documentation Required

Order specificity for quantitative tests

Quantitative testing must be ordered with the specific drug to be confirmed and not as a comprehensive confirmatory panel; order must be placed by the treating medical provider at time of order.

Affected codes: G0480, G0481, G0482, G0483, G0659

Billing Rule

Daily unit limit

Testing is limited to one unit per day per test type (qualitative or quantitative); claims exceeding this may be denied.

Affected codes: 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659
Limit: one (1) unit per day per test type

Billing Rule

Specimen validity testing billing restriction

Do not separately bill validity testing (e.g., urinary pH, specific gravity, creatinine, nitrates, oxidants) when performed as part of drug testing; these are internal control processes.

Specimen validity tests are internal controls and not separately billable

Denial Risk

Non-covered uses

Claims for drug screening for medico-legal (court-ordered) or employment purposes, routine testing (at every visit), testing under bundled SUD program rates, or testing ordered by/for third parties solely to meet third-party requirements are not covered and may be denied.

Documentation Required

Medical necessity and prior auth

Providers must verify eligibility, coverage, and authorization criteria prior to services; Neighborhood may require adherence to NCD/LCD/InterQual/CMP/EOHHS standards when determining medical necessity.

Billing Rule

Specimen source simultaneous testing

It is not reasonable or necessary to test for the same drug with both a blood and a urine specimen simultaneously; such billing may be considered inappropriate.

OpenPayer

Drug Testing Payment Policy – Archive 2

Policy summary & scope

Coverage criteria and medical necessity

Billing codes and code guidance

Billing, documentation, and denial risks

Definitions

Policy revision timeline