Urine Drug Testing

Policy No: 106
Originally Created: 01/01/2011
Section: Medicine
Last Reviewed: 08/01/2023
Last Revised: 06/01/2023
Approved: 08/10/2023
Effective: 09/01/2023
Policy applies to: Group and Individual

This policy applies to ASCs, physicians, laboratories, other qualified health care professionals, hospitals, and other facilities.

Presumptive Testing
A test used to detect the presence of a drug in a urine sample. The test is performed by a provider with Certificate of Waiver or a Medical Test Site Accredited License. Findings are reported qualitatively as either positive or negative.

Definitive Testing
Definitive tests are performed in a laboratory or by a provider with Certificate of Registration, Compliance of Accreditation or Medical Test Site Categorized License or Accredited License. The tests quantify the amount of drug or metabolite present in the urine sample. Definitive tests can be used to confirm the presence of a specific drug identified by a screening test and can identify drugs that cannot be isolated by currently available presumptive testing. Results are reported as specific levels of substances detected in the urine sample.

Current Procedural Terminology (CPT®) 80305 - 80307 - Drug test(s) presumptive, any number of drug classes; any number of devices or procedures (e.g., immunoassay), includes sample validation when performed, per date of service.

CPT 0007U - Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service.

CPT 0227U - Drug assay, presumptive, 30 or more drugs or metabolites, urine, liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, includes sample validation.

Healthcare Common Procedure Coding System (HCPCS) - G0480, G0481 and G0659 - Drug test(s) definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomer (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase); qualitative or quantitative, all sources, includes specimen validity testing, per day.

CPT codes 80320-80377, 0082U, and 83992 are not eligible for reimbursement.

HCPCS codes G0482 and G0483 are not eligible for reimbursement.

Presumptive Testing
Presumptive drug tests must be reported using procedure codes 80305-80307, 0007U or 0227U. Reimbursement for procedure codes 80305-80307, 0007U or 0227U is limited to one unit per day. Only one of the five codes may be billed per day.

Definitive Testing
Definitive drug tests must be reported using procedure codes G0480, G0481 or G0659. Reimbursement for procedure codes G0480, G0481 or G0659 is limited to one unit per day. The units used to determine the appropriate code to bill is "drug class." The number of drug classes tested determines the appropriate code to use. Each drug class may only be used once per day. Only one of the three codes may be billed per day.

Modifiers
Modifiers 59, XE, XP, XS, XU and 91 should not be reported with procedure codes 80305-80307, 0007U, 0227U, G0480, G0481 and G0659. These modifiers will not bypass the edit.

Guidelines
Presumptive codes are eligible for reimbursement when testing is performed in an office, laboratory or facility setting. These codes are not eligible for reimbursement for chemical dependency facilities.

The definitive tests must be both more sensitive and specific than the initial screen.

Testing performed as described below is not eligible for reimbursement:

• Testing as required for, or in conjunction with, participation in chemical dependency facilities, at higher levels of treatment, (e.g., residential, inpatient, partial hospitalization). Urine drug presumptive or definitive testing is considered included in the facility reimbursement.
• Unbundled tests when using a multi-test kit screening (e.g., strip, dip card, or cassette)
• Definitive testing as a routine supplement to drug screens, or in lieu of drug screens except when immunoassay testing is not commercially available.
• Presumptive testing performed in conjunction with definitive testing
• Standing orders for definitive testing also known as "custom profile"
• Testing ordered by or for third parties (such as courts, schools, military, or employers) or ordered for the sole purpose of meeting the requirements of a third party.

• Specimen collection and preparation (included in reimbursement for the testing)

Routine billing of specimen validation is not eligible for reimbursement.

Pass through billing is not eligible for reimbursement. Medically necessary definitive testing must be performed by, and billed by, a laboratory participating with our health plan.

The use of non-participating laboratories may subject our members to unnecessary services not ordered by the treating provider, or other unreasonable financial exposure. In such circumstances, we may hold the treating or referring provider financially liable for any services deemed to be not medically necessary or non-reimbursable if the treating or referring provider referred the specimen or member to the non-participating laboratory.

Claims received for urine drug screen testing are processed based on the date the claim is received.

Facilities that are reimbursed at a global rate are responsible for the entire package of care that the member receives from, or which are ordered by the facility during that stay. When services (e.g., Lab services, Ancillary Services, etc.) are performed by other entities at the request of the facility, they are not separately reimbursable during that stay.

American Medical Association, Current Procedural Terminology (CPT®)

Bundling Edits

Non-Reimbursable Services

Correct Coding Guidelines

Drug Testing for Substance Abuse and Pain Management, Medical Policy, Lab 68