CurrentUnitedHealthcarePolicy N/A

Drug testing reimbursement (presumptive, definitive, specimen validity)

Defines daily and annual limits, reimbursement rules, and state exceptions for presumptive and definitive drug testing services billed to UnitedHealthcare Community Plan Medicaid products.

Policy Summary

PayerUnitedHealthcare

PolicyDrug testing reimbursement (presumptive, definitive, specimen validity)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReport presumptive and definitive drug testing once per patient per day; specimen validity testing is included and not separately reimbursable when performed same date as a presumptive or definitive test.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/dayAllowed presumptive per patient per date

1/dayAllowed definitive per patient per date

18 DOSAnnual limit - presumptive

18 DOSAnnual limit - definitive

ListedState-specific deviations

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Coverage Criteria for Drug Testing

Coverage criteria for drug testing

UnitedHealthcare Community Plan reimburses presumptive and definitive drug testing subject to daily reporting limits, inclusion of specimen validity testing in those code descriptions, annual unit-of-service (UOS) limits, and state-specific exceptions.

ALL of the following

Presumptive and definitive drug testing services are reimbursed when reported in accordance with CPT/CMS code descriptions and guidelines (see applicable presumptive and definitive codes).
Each presumptive drug testing code represents all drug and Drug Class tests performed by the respective methodology per date of service and is a single per‑patient service reported once per date of service.
Each definitive drug testing code (including HCPCS G0480–G0483, G0659, CPT 80320–80377 and 83992, and applicable PLA codes) is reported per Drug Class category once per date of service; multiple definitive procedures for the same drug class on a date of service are not separately reported beyond the class-level reporting.
Specimen validity testing is considered part of the presumptive and definitive drug testing CPT and HCPCS code descriptions (quality control for collection) and is NOT separately reimbursable when performed on the same date of service as a presumptive and/or definitive drug test by the same or different provider. A modifier may be appropriate only when specimen validity testing is performed distinctly separate from the drug test and documentation supports that it was unrelated to the drug testing.
Daily reporting limit: Allow only one presumptive drug test and one definitive drug test reported per patient per date of service (one per day).
Annual frequency limits
- An annual UOS limitation of 18 dates of service applies for presumptive drug testing (applies whether services are provided by the same or different providers).18 dates of service
- An annual UOS limitation of 18 dates of service applies for definitive drug testing (HCPCS and CPT Drug Class codes), (applies whether services are provided by the same or different providers).18 dates of service
Exclusions and denials
- Specimen validity testing performed on the same date of service as a presumptive and/or definitive drug test will be denied (not separately reimbursable).
- Drug testing services that are court-ordered and/or funded by a county, state, or federal agency will be denied (refer to Services and Modifiers Not Reimbursable to Healthcare Professionals Policy).
State exceptions: State-specific deviations from baseline daily and annual limits apply where noted in the policy (some states are exempt from the 18 DOS annual limit or have alternative unit limits for specific codes).

Relevant CPT/PLA Codes and Billing Limits

Presumptive Drug Testing CodesCPTCovered

80305	Presumptive drug testing
80306	Presumptive drug testing
80307	Presumptive drug testing
H0003	Presumptive drug testing (substance abuse screening)

Presumptive Drug Testing Codes (alternate view)mixedCovered

80305	Presumptive drug testing
80306	Presumptive drug testing
80307	Presumptive drug testing
H0003	Presumptive drug testing (substance abuse screening)

Definitive Drug Testing CodesmixedCovered

0007U	Proprietary definitive drug testing (PLA)
0011U	Proprietary definitive drug testing (PLA)
0082U	Proprietary definitive drug testing (PLA)
0328U	Proprietary definitive drug testing (PLA)
G0480	Definitive drug testing (HCPCS)
G0481	Definitive drug testing (HCPCS)
G0482	Definitive drug testing (HCPCS)
G0483	Definitive drug testing (HCPCS)
G0659	Definitive drug testing (HCPCS)
0517U	Definitive drug testing (PLA)

1–10 of 16

1/2

Specimen Validity Testing Codes (examples)CPTNot Covered

81000	Specimen validity / urinalysis-related codes (not separately reimbursable with drug test)
81001	Specimen validity
81002	Specimen validity
81003	Specimen validity
81005	Specimen validity

inv-05: Annual UOS limit - presumptive

Annual unit-of-service limit18 dates of service per year for presumptive drug testing

Daily reporting ruleOne presumptive drug test allowed per patient per date of service (same or different provider)

Applies across providersLimit applies whether services are provided by the same or different provider

inv-06: Annual UOS limit - definitive

Annual unit-of-service limit18 dates of service per year for definitive drug testing

Daily reporting ruleOne definitive drug test within the definitive Drug Class allowed per patient per date of service (same or different provider)

Provider Billing Rules and Exceptions

Billing Rule

Daily reporting limit; specimen validity included — not separately reimbursable

Report presumptive and definitive drug testing once per patient per date of service; specimen validity testing is included in the presumptive and definitive code descriptions and is not separately reimbursable when performed on the same date of service. A modifier may be appropriate when specimen validity testing is performed distinctly separate from the drug test and documentation supports that it was not related to the drug testing.

Report only one presumptive drug test and one definitive drug test per patient per date of service.
Specimen validity testing is considered quality control and will be denied if billed the same date as a presumptive and/or definitive drug test unless properly documented as separate (modifier may be appropriate).

Billing Rule

Annual frequency limits — 18 dates of service each

Annual unit-of-service limits apply: 18 dates of service per year for presumptive drug testing and 18 dates of service per year for definitive drug testing. These limits apply whether services are provided by the same or different providers, unless state-specific exceptions apply.

Definitions

inv-10: Drug Class — definition of drug class

DefinitionA group of drugs that have the same chemical structure, work in the same way and/or are used for the same purpose.

Reporting noteEach category of a drug class, including metabolites if performed, is reported once per date of service.

ExamplesAlcohols, amphetamines, benzodiazepines, cocaine and metabolites, methadone, opioid analgesics, antipsychotics, etc.

inv-11: Proprietary Laboratory Analysis (PLA) Codes — definition and notes

DefinitionProprietary Laboratory Analysis (PLA) codes describe proprietary clinical laboratory analysis and can be provided by a single ('sole source') laboratory or licensed/marketed to multiple providing laboratories.

IncludesThese codes include advanced diagnostic laboratory tests (ADLTs) and clinical diagnostic laboratory tests (CDLTs) as defined under PAMA.