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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 04/01/2012 Title: Testing for Drugs of Abuse
Revision Date: 09/01/2020 Document: BI345:00
CPT Code(s): 80100, 80102, 80104, 80300-80307, 80320-80377, 82077, 83992, G0431, G0434, G0477-G0483, 0006U, 0007U, 0011U, 0020U, 0093U, 01164U, 01174U, 0227U
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Periodic urine drug screening may be useful in monitoring pain therapy compliance.  Screening is also appropriate in pregnancy or prior to performing Multiple Sleep Latency Testing. In these circumstances, a simple screening test is appropriate and is covered.  Mandated drug screening or testing for work or legal purposes is not covered.  Definitive testing is not covered at out-of-network labs.

This policy does not limit the use of drug screening in emergency or inpatient care. 


Medical Statement

1)    Urine screening for drugs of abuse in the outpatient setting will be considered medically necessary when the result will influence medical care, such as in: 

                                  i.    Pregnancy, or

                                ii.    Patients taking narcotic pain medications on a chronic basis, or

                               iii.    Prior to performing a Multiple Sleep Latency Test. 

2)    A multiplex drug screen either performed in the physician’s office or in a laboratory, is the appropriate test in these circumstances. Presumptive drug screening (80305 or 80306) are the only tests that will be covered when billed by the physician’s office, and will be covered only once per day, and upto 2 per month and 24 per 12 months. CPT codes adequately describe these tests, therefore HCPCS codes will not be accepted. Any other drug testing, whether presumptive or definitive, billed by the physician’s office, will be denied, provider liability, as inappropriately coded.

3)    Presumptive testing (80307) by a laboratory, ER or inpatient facility or definitive testing (80320 - 80377) is limited to once per day. Standard CPT codes adequately describe these tests, therefore temporary CPT codes or HCPCS codes will not be accepted. 

4)    Definitive testing is appropriate when a preceding drug screen is positive, and will be considered medically necessary for those drugs with a positive screening test. If initial screening performed has negative findings for a specific drug, additional testing for that drug on same day will be denied as not medically necessary. Definitive testing may also be appropriate for drugs that have been prescribed for the patient but are not included in the available presumptive test. Confirmatory testing will be covered only when billed by a facility laboratory or an independent in-network laboratory. Out-of-network laboratories are not covered for this type of testing.

 

Codes Used In This BI:

 

0006U

Rx drug monitoring, 120 + drugs & substances, qualitative urine

0007U

Presumptive drug test(s) urine, any number of drug classes, includes DNA authen

0011U

Rx drug monitoring, by LC-MS/MS, using oral fluid

0020U

Presumptive drug test(s) urine, any number of drug classes, includes DNA authen

0093U

Prescription drug monitoring, evaluation of 65 common drugs by LC-MS/MS,  urine, each drug reported detected or not detected

0116U

RX MNTR NZM IA 35+DRUGS LC-MS/MS ORAL FLUID ALG (new temporary code 10/1/19)

0117U

PAIN MGMT ALYS 11 ENDOGENOUS ANALYTES URINE ALG (new temporary code 10/1/19)

80300

Drug screen, multi-class frm Drug Class List A, smpl, per day (del 1/1/17)

80301

Drug screen, sgl class, frm Drug Class List A, cplx, per day (deleted 1/1/17)

80302

Drug screen, presumpe, sglclass frm Drug Class List B, ea (deleted 1/1/17)

80303

Drug screen, multi-class frm Drug Class List B, per day (deleted 1/1/17)

80304

Drug screen, presump, NOS, ea (deleted 1/1/17)

80305

Drug screen, presumptive, optical (new 1/1/17)

80306

Drug screen, presumptive, instrument assisted optical (new 1/1/17)

80307

Drug screen, presumptive, instrument chemistry analyzer (new 1/1/17)

80320

Alcohols

80321

Alcohol biomarkers, 1-2

80322

    3 or more

80323

Alkaloids

80324

Amphetamines, 1-2

80325

    3-4

80326

    5 or more

80327

Anabolic steroids, 1-2

80328

    3 or more

80329

Analgesics, non-opioid, 1-2

80330

    3-5

80331

    6 or more

80332

Antidepressants, serotinergic, 1-2

80333

    3-5

80334

    6 or more

80335

Antidepressants, cyclicals, 1-2

80336

    3-5

80337

    6 or more

80338

Antidepressants, NOS

80339

Antiepileptics, NOS, 1-3

80340

    4-6

80341

    7 or more

80342

Antipsychotics, NOS, 1-3

80343

    4-6

80344

    7 or more

80345

Barbiturates

80346

Benzodiazepines, 1-12

80347

    13 or more

80348

Buprenorphine

80349

Cannabinoids, natural

80350

Cannabinoids, synthetic, 1-3

80351

    4-6

80352

    7 or more

80353

Cocaine

80354

Fentanyl

80355

Gabapentin, non-blood

80356

Heroin metabolite

80357

Ketamine and norketamine

80358

Methadone

80359

Methylenedioxyamphetamines (MDA, MDEA, MDMA)

80360

Methylphenidate

80361

Opiates, 1 or more

80362

Opioids and opiate analogs, 1-2

80363

    3-4

80364

    5 or more

80365

Oxycodone

80366

Pregabalin

80367

Propoxyphene

80368

Sedative hypnotics (non-benzodiazepine)

80369

Skeletal muscle relaxants, 1-2

80370

    3 or more

80371

Stimulants, synthetic

80372

Tapentadol

80373

Tramadol

80374

Stereoisomer analysis, single class

80375

Drugs, NOS, 1-3

80376

    4-6

80377

    7 or more

83992

Phencyclidine

G0431

Drug screen multi drug class (deleted 1/1/16)

G0434

Drug screen multi drug class (deleted 1/1/16)

G0477

Drug test(s); by direct optical observation (deleted 1/1/17)

G0478

Drug test(s); by instrument-assisted direct optical observation (deleted 1/1/17)

G0479

Drug test(s); by instrumented chemistry analyzers (deleted 1/1/17)

G0480

Drug test(s); definitive; per day; 1-7

G0481

Drug test(s); definitive; per day; 8-14

G0482

Drug test(s); definitive; per day; 15-21

G0483

Drug test(s); definitive; per day; 22+

82077

Alcohol (ethanol); any specimen except urine and breath, immunoassay (eg, IA, EIA, ELISA, RIA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase) (new code eff 01/01/2021)

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 (new code eff 01/01/2021)


Limits

HCPCS codes G0480 - G0483 and temporary CPT codes 0006U, 0007U, 0011U, 0020U, 0093U, 0116U and 0017U are not covered. The procedures these codes are used for are considered to be adequately described by standard CPT codes.


Background

Screening for use of drugs of abuse is carried out extensively in the workplace and legal settings.  That sort of screening is not carried out for medical purposes, and is not considered eligible for benefits.

Screening for use of drugs of abuse is commonly performed in the emergency room setting to rapidly confirm or rule out medical problems caused by these drugs.  Screening in that setting is also not addressed in this policy, but falls under general rules of medical necessity.

Extensive use of drug testing for employment screening by industry has refined available testing options.  Multiplex enzyme or immunoassay based drug tests are available on a CLIA waived basis, and can be used at the point of service to give rapid drug screen results.  The efficacy of such tests for identifying recent drug use is well established.  False positives remain an issue with such tests, and confirmation, typically with gas chromatography, is required to rely on a positive result. 

There are two common situations in which screening for use of drugs of abuse is medically indicated in patients without signs of drug intoxication:  in pregnancy, and in patients who are in a chronic pain management program and are being prescribed medications that could be abused, misused, or diverted.  Additionally, screening is recommended in patients undergoing a Multiple Sleep Latency Test (MSLT).  This policy addresses appropriate use of drug screening and confirmation tests in these settings.

In the setting of pregnancy, the medical necessity is to rule out the use of drugs that may adversely affect the fetus or the outcome of the pregnancy.  A multiplex drug screen that tests for the common drugs of abuse in the community appropriately answers that question.  If the screen is negative, no further confirmation is required.  If the screen is positive for one or more drugs of abuse, confirmation is required only for those drugs with a positive screening test.

In the setting of chronic use of narcotic or other medications subject to abuse, the medical necessity is twofold.  The prescribing physician wants to know that the patient is taking the prescribed medication, and that the patient is not taking other drugs of abuse that would violate the pain contract and increase the risk of toxicity.  Again, the appropriate initial test is a urine drug screen.  Confirmatory testing would only be required for those drugs with a positive screening test, or for confirmation of use in patients who have been prescribed particular medications.  All such drug testing should be driven by the needs of the particular patient; it would not be considered medically necessary, for example, to test for the presence of antidepressant medications in patients who have not had such medication prescribed.

The MSLT is indicated to confirm the diagnosis of narcolepsy in a patient suspected of the disorder, and may be indicated as part of the evaluation of patients with suspected idiopathic hypersomnia to help differentiate idiopathic hypersomnia from narcolepsy.  The test is performed immediately following polysomnography.  Drug screening, typically performed on the morning of the MSLT, is indicated to ensure that sleepiness on the MSLT is not pharmacologically induced.

The only drug screening that would typically be performed in the office setting, rather than being sent to an independent laboratory, is presumptive testing for drugs that can be read by optical observation or instrument assisted direct optical observation.  QualChoice will cover this screening if billed by the provider office, but will cover other testing only when billed by the lab that actually performs the testing.


Reference

Standards of Practice Committee of the American Academy of Sleep Medicine.  Practice parameters for Clinical Use of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test.  Sleep 2005; 28(1):113-121

2. American College of Occupational and Environmental Medicine.  Chronic pain.  In: Occupational medicine practice guidelines; 2008: 73-502.

3. Colorado Division of Worker’s Compensation.  Chronic pain disorder medical treatment guidelines.  2011 Dec 27.

4. Management of Opioid Therapy for Chronic Pain Working Group.  VA/DoD clinical practice guideline for management of opioid therapy for chronic pain.  2010 May.

Addendum:

1.    Effective 01/01/2017: the AMA CPT classification no longer distinguishes between Class A and Class B drugs. The 2017 AMA CPT classification distinguishes between simple optical screening tests which are commonly performed in a CLIA waived office lab and instrument chemistry analyzers that are more typically seen in a commercial laboratory.  While presumptive drug screening can be performed either way, definitive or confirmatory testing is best done by a commercial laboratory with instrument chemistry analyzers. Updated with 2017 CPT codes.  Noted deletion of the following HCPCS codes, effective 1/1/17: G0477 – G0479. Updated with new codes.

2.    Effective 01/01/2018: Testing for drugs of abuse (80307 - 80377) will not be covered at out-of-network (OON) labs.

3.    Effective 10/01/2018: Aligned quantity limits with standard (once daily) NCCI edits.

4.    Effective 07/01/2019: Added new code (0093U).

5.    Effective 10/01/2019: Added new temporary CPT codes.

6.    Effective 09/01/2020: presumptive drug testing (CPT 80305-80306) is covered not more than once per day, or 2 per month and 24 per 12 months. Confirmatory drug testing is also covered once per day and up to twice a month and 24 per 12 months.

7.    Effective 01/01/2021: Added new code 0227U, as noncovered. CPT 82077 is considered experimental and investigational and is not covered.

8.    Effective 05/01/2021: drug testing (CPT 80305 to 80377) are cumulatively covered for not more than once per day, or 2 per month and 24 per 12 months.

Resource Document:

BI345 Testing for Drugs of Abuse RD


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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