Drug Testing

Section: Laboratory
Effective Date: January 01, 2020
Revised Date: November 15, 2019
Last Reviewed: September 26, 2019

Description

Individuals in pain management and substance abuse treatment programs may misuse prescribed opioids and/or may use non-prescribed drugs. Therefore, individuals in these settings are often assessed before treatment and monitored while they are receiving treatment. Drug screening is one monitoring strategy; it is most often used as part of a multifaceted intervention that includes other components such as individual contracts.

Presumptive (i.e., qualitative, immunoassay) tests are usually performed at the point of service (POS). Immunoassay tests are based on the principle of competitive binding and use antibodies to detect a particular drug or drug metabolite in a sample.

Definitive (i.e., confirmatory, quantitative) tests are always performed in a laboratory and assess multiple drugs at one time. Individual tests are specific to one drug only. Definitive testing is a panel that includes individual drug tests and the associated levels of the specific drugs. Definitive drug testing is more cost effective than individual testing. Gas chromatography/mass spectrometry (GC/MS) is considered to be the gold standard for confirmatory testing.

Criteria

Routine presumptive urine drug testing in substance use disorder treatment (i.e, testing at every visit or without consideration for specific individual risk factors) is considered not medically necessary.

Procedure Code

80305 80306 80307

Specimen validation testing is inherent to presumptive and confirmatory testing and is considered not medically necessary.

Procedure Codes

82542 82570 83986 84311 84315

Definitive (i.e., confirmatory, quantitative) drug testing may be considered medically necessary under ANY ONE of the following conditions:

  • When performed as a reflex by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory after a positive presumptive test when ANY ONE of the following are met:
    • To verify a presumptive positive urine drug test before reporting the presumptive finding to the ordering clinician and without an additional order from the clinician; or
    • In specific situations for which definitive testing is required for clinical decision making and would significantly change a treatment plan (e.g., to distinguish drug supplementation from products of minor metabolic pathways; to help identify patients diverting medications); or
    • To identify non-prescribed medication or illicit substance use so as to allow safe prescribing of controlled substances, where the clinician has documented concerns related to safety risks that may arise due to failure to identify non-prescribed medications or illicit substances; or
  • When presumptive drug tests are not available for the drug(s) for which there is a suspicion of abuse or misuse and ALL of the following criteria are met:
    • The clinical presentation of the individual being testing supports the need for the specific drug testing being requested; and
    • Results of testing will impact treatment; and
    • Testing is performed in a CLIA certified laboratory.

Definitive and presumptive drug testing is considered not medically necessary when the above criteria are not met.

Procedure Codes

80375 80376 80377 G0480 G0481 G0482 G0483
G0659

Limitations

Presumptive drug testing may be considered medically necessary and will only be allowed one (1) per date of service regardless of the number of drug classes tested.

Quantity level limits (QLLs) are considered not medically necessary when the frequency guidelines listed above are exceeded.

Procedure Codes

80305 80306 80307

Presumptive drug testing, when billed in any combination, may be considered medically necessary and will be limited to 24 tests in a benefit period regardless of test performed.

QLLs are considered not medically necessary when the frequency guidelines listed above are exceeded.

Procedure Codes

80305 80306 80307

Definitive drug testing, when billed in any combination, may be considered medically necessary and will be allowed one (1) service per date with a limit of 24 tests per benefit period.

QLLs are considered not medically necessary when the frequency guidelines listed above are exceeded.

Procedure Codes

80375 80376 80377 G0480 G0481 G0482 G0483
G0659

Individual drug tests are considered not medically necessary.

Procedure Codes

80320 80321 80322 80323 80324 80325 80326
80327 80328 80332 80333 80334 80335 80336
80337 80338 80345 80346 80347 80348 80349
80350 80351 80352 80353 80354 80355 80356
80357 80358 80359 80360 80361 80362 80363
80364 80365 80366 80367 80368 80369 80370
80371 80372 80373 80374 83992

The following drug tests are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

  • Hair drug testing; and
  • Oral fluid drug testing; and
  • Meconium drug testing

Procedure Codes

0006U 0007U 0011U 0051U 0054U 0082U 0116U
0117U

The collection date of the specimen must equal the date of service for the drugs tested.

Benefit year limits do not apply to the following:

  • Emergency room visits
  • Inpatient admissions
  • Federally regulated testing

The following tests are considered non-covered:

  • Non-forensic testing (i.e. job related testing)
  • State/legally mandated drug testing

Professional Statements and Societal Positions

42 CFR 8.12 – Federal opioid treatment standards 2017

An Opioid Treatment Programs (OTPs) organizational structure and facilities shall be adequate to ensure quality patient care and to meet the requirements of all pertinent Federal, State, and local laws and regulations. At a minimum, each OTP shall formally designate a program sponsor and medical director. The program sponsor shall agree on behalf of the OTP to adhere to all requirements set forth in this part and any regulations regarding the use of opioid agonist treatment medications in the treatment of opioid use disorder which may be promulgated in the future. The medical director shall assume responsibility for administering all medical services performed by the OTP. In addition, the medical director shall be responsible for ensuring that the OTP is in compliance with all applicable Federal, State, and local laws and regulations.

Centers for Disease Control and Prevention (CDC) 2016:

  • When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

The guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death.

Substance Abuse and Mental Health Service Administration (SAMHSA) 2015 
Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that a combination of medication and therapy can successfully treat these disorders, and for some people struggling with addiction, MAT can help sustain recovery.

Federal legislation, regulations, and guidelines govern MAT for opioid addiction. SAMHSA’s Division of Pharmacologic Therapies (DPT), part of the SAMHSA Center for Substance Abuse Treatment (CSAT), oversees accreditation standards and certification processes for OTPs. DPT also works with the Drug Enforcement Administration (DEA) and the states to regulate certain medications used in MAT. Additionally, DPT works directly with MAT professionals to improve treatment outcomes and to meet regulatory criteria.

American Society of Addiction Medicine (ASAM) 2017

Appropriate Use of Drug Testing in Clinical Addiction Medicine was published by ASAM in 2017.

  • “As a general principle, drug testing should be scheduled more frequently at the beginning of treatment. The Expert Panel recommends that a patient in early recovery be tested at least weekly. As the patient becomes more stable in recovery, the frequency of drug testing should be decreased, but performed at least on a monthly basis. Individual consideration may be given for less frequent testing if a patient is in stable recovery. If the patient returns to substance use after a period of abstinence, the provider should resume the early recovery testing schedule, possibly in conjunction with an adapted or intensified treatment plan.”

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 80305, 80306, 80307, 80375, 80376, 80377, G0480, G0481, G0482, G0483 and G0659    

F10.10 F10.120 F10.121 F10.129 F10.150 F10.151 F10.159
F10.180 F10.181 F10.182 F10.188 F10.20 F10.21 F10.220
F10.221 F10.229 F10.230 F10.231 F10.232 F10.239 F10.24
F10.250 F10.251 F10.259 F10.26 F10.27 F10.280 F10.281
F10.282 F10.288 F10.29 F10.920 F10.921 F10.929 F10.94
F10.950 F10.951 F10.959 F10.96 F10.97 F10.980 F10.981
F10.982 F10.988 F10.99 F11.10 F11.11 F11.14 F11.19
F11.20 F11.21 F11.23 F11.24 F11.29 F11.90 F11.93
F11.94 F11.120 F11.121 F11.122 F11.129 F11.150 F11.151
F11.159 F11.181 F11.182 F11.188 F11.220 F11.221 F11.222
F11.229 F11.250 F11.251 F11.259 F11.281 F11.282 F11.288
F11.920 F11.921 F11.922 F11.929 F11.950 F11.951 F11.959
F11.981 F11.982 F11.988 F12.10 F12.120 F12.121 F12.122
F12.129 F12.150 F12.151 F12.159 F12.180 F12.188 F12.19
F12.20 F12.21 F12.220 F12.221 F12.222 F12.229 F12.250
F12.251 F12.259 F12.280 F12.288 F12.29 F12.90 F12.920
F12.921 F12.922 F12.929 F12.950 F12.951 F12.959 F12.980
F12.988 F12.99 F13.10 F13.120 F13.121 F13.129 F13.14
F13.150 F13.151 F13.159 F13.180 F13.181 F13.182 F13.188
F13.19 F13.20 F13.21 F13.220 F13.221 F13.229 F13.230
F13.231 F13.232 F13.239 F13.24 F13.250 F13.251 F13.259
F13.26 F13.27 F13.280 F13.281 F13.282 F13.288 F13.29
F13.90 F13.920 F13.921 F13.929 F13.930 F13.931 F13.950
F13.951 F13.959 F13.96 F13.97 F13.980 F13.981 F13.982
F13.988 F13.99 F14.10 F14.14 F14.19 F14.20 F14.21
F14.23 F14.24 F14.29 F14.90 F14.94 F14.99 F14.120
F14.121 F14.122 F14.129 F14.150 F14.151 F14.159 F14.180
F14.181 F14.182 F14.188 F14.220 F14.221 F14.222 F14.229
F14.250 F14.251 F14.259 F14.280 F14.281 F14.282 F14.288
F14.920 F14.921 F14.922 F14.929 F14.950 F14.951 F14.959
F14.980 F14.981 F14.982 F14.988 F15.10 F15.120 F15.121
F15.122 F15.129 F15.150 F15.151 F15.159 F15.180 F15.181
F15.182 F15.188 F15.19 F15.20 F15.21 F15.220 F15.221
F15.222 F15.229 F15.23 F15.24 F15.250 F15.251 F15.259
F15.280 F15.281 F15.282 F15.288 F15.29 F15.90 F15.920
F15.921 F15.922 F15.929 F15.93 F15.94 F15.950 F15.951
F15.959 F15.980 F15.981 F15.982 F15.988 F15.99 F16.10
F16.14 F16.19 F16.20 F16.21 F16.24 F16.29 F16.90
F16.94 F16.99 F16.120 F16.121 F16.122 F16.129 F16.150
F16.151 F16.159 F16.180 F16.183 F16.188 F16.220 F16.221
F16.229 F16.250 F16.251 F16.259 F16.280 F16.283 F16.288
F16.920 F16.921 F16.929 F16.950 F16.951 F16.959 F16.980
F16.983 F16.988 F18.10 F18.11 F18.120 F18.121 F18.129
F18.14 F18.150 F18.151 F18.159 F18.17 F18.180 F18.188
F18.19 F18.20 F18.21 F18.220 F18.221 F18.229 F18.24
F18.250 F18.251 F18.259 F18.27 F18.280 F18.288 F18.29
F18.90 F18.920 F18.921 F18.929 F18.94 F18.950 F18.951
F18.959 F18.97 F18.99 F19.10 F19.120 F19.121 F19.122
F19.129 F19.14 F19.150 F19.151 F19.159 F19.16 F19.17
F19.180 F19.181 F19.182 F19.188 F19.220 F19.221 F19.222
F19.229 F19.230 F19.231 F19.232 F19.239 F19.24 F19.250
F19.251 F19.259 F19.26 F19.27 F19.280 F19.281 F19.282
F19.288 F19.29 F19.90 F19.920 F19.921 F19.922 F19.929
F19.930 F19.931 F19.932 F19.939 F19.94 F19.950 F19.951
F19.959 F19.96 F19.97 F19.980 F19.981 F19.988 F19.99
F45.42 G89.4 G89.21 G89.22 G89.28 G89.29 O99.320
O99.321 O99.322 O99.323 O99.324 Z51.81 Z76.0 Z79.891
Z79.899

Non-Covered Diagnosis Codes for Procedure Codes 80320, 80321, 80322, 80323, 80324, 80325, 80326, 80327, 80328, 80332, 80333, 80334, 80335, 80336, 80337, 80338, 80345, 80346, 80347, 80348, 80349, 80350, 80351, 80352, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80363, 80364, 80365, 80366, 80367, 80368, 80369, 80370, 80371, 80372, 80373, 80374 and 83992

F10.10 F10.120 F10.121 F10.129 F10.150 F10.151 F10.159
F10.180 F10.181 F10.182 F10.188 F10.20 F10.21 F10.220
F10.221 F10.229 F10.230 F10.231 F10.232 F10.239 F10.24
F10.250 F10.251 F10.259 F10.26 F10.27 F10.280 F10.281
F10.282 F10.288 F10.29 F10.920 F10.921 F10.929 F10.94
F10.950 F10.951 F10.959 F10.96 F10.97 F10.980 F10.981
F10.982 F10.988 F10.99 F11.10 F11.11 F11.14 F11.19
F11.20 F11.21 F11.23 F11.24 F11.29 F11.90 F11.93
F11.94 F11.120 F11.121 F11.122 F11.129 F11.150 F11.151
F11.159 F11.181 F11.182 F11.188 F11.220 F11.221 F11.222
F11.229 F11.250 F11.251 F11.259 F11.281 F11.282 F11.288
F11.920 F11.921 F11.922 F11.929 F11.950 F11.951 F11.959
F11.981 F11.982 F11.988 F12.10 F12.120 F12.121 F12.122
F12.129 F12.150 F12.151 F12.159 F12.180 F12.188 F12.19
F12.20 F12.21 F12.220 F12.221 F12.222 F12.229 F12.250
F12.251 F12.259 F12.280 F12.288 F12.29 F12.90 F12.920
F12.921 F12.922 F12.929 F12.950 F12.951 F12.959 F12.980
F12.988 F12.99 F13.10 F13.120 F13.121 F13.129 F13.14
F13.150 F13.151 F13.159 F13.180 F13.181 F13.182 F13.188
F13.19 F13.20 F13.21 F13.220 F13.221 F13.229 F13.230
F13.231 F13.232 F13.239 F13.24 F13.250 F13.251 F13.259
F13.26 F13.27 F13.280 F13.281 F13.282 F13.288 F13.29
F13.90 F13.920 F13.921 F13.929 F13.930 F13.931 F13.950
F13.951 F13.959 F13.96 F13.97 F13.980 F13.981 F13.982
F13.988 F13.99 F14.10 F14.14 F14.19 F14.20 F14.21
F14.23 F14.24 F14.29 F14.90 F14.94 F14.99 F14.120
F14.121 F14.122 F14.129 F14.150 F14.151 F14.159 F14.180
F14.181 F14.182 F14.188 F14.220 F14.221 F14.222 F14.229
F14.250 F14.251 F14.259 F14.280 F14.281 F14.282 F14.288
F14.920 F14.921 F14.922 F14.929 F14.950 F14.951 F14.959
F14.980 F14.981 F14.982 F14.988 F15.10 F15.120 F15.121
F15.122 F15.129 F15.150 F15.151 F15.159 F15.180 F15.181
F15.182 F15.188 F15.19 F15.20 F15.21 F15.220 F15.221
F15.222 F15.229 F15.23 F15.24 F15.250 F15.251 F15.259
F15.280 F15.281 F15.282 F15.288 F15.29 F15.90 F15.920
F15.921 F15.922 F15.929 F15.93 F15.94 F15.950 F15.951
F15.959 F15.980 F15.981 F15.982 F15.988 F15.99 F16.10
F16.14 F16.19 F16.20 F16.21 F16.24 F16.29 F16.90
F16.94 F16.99 F16.120 F16.121 F16.122 F16.129 F16.150
F16.151 F16.159 F16.180 F16.183 F16.188 F16.220 F16.221
F16.229 F16.250 F16.251 F16.259 F16.280 F16.283 F16.288
F16.920 F16.921 F16.929 F16.950 F16.951 F16.959 F16.980
F16.983 F16.988 F18.10 F18.11 F18.120 F18.121 F18.129
F18.14 F18.150 F18.151 F18.159 F18.17 F18.180 F18.188
F18.19 F18.20 F18.21 F18.220 F18.221 F18.229 F18.24
F18.250 F18.251 F18.259 F18.27 F18.280 F18.288 F18.29
F18.90 F18.920 F18.921 F18.929 F18.94 F18.950 F18.951
F18.959 F18.97 F18.99 F19.10 F19.120 F19.121 F19.122
F19.129 F19.14 F19.150 F19.151 F19.159 F19.16 F19.17
F19.180 F19.181 F19.182 F19.188 F19.220 F19.221 F19.222
F19.229 F19.230 F19.231 F19.232 F19.239 F19.24 F19.250
F19.251 F19.259 F19.26 F19.27 F19.280 F19.281 F19.282
F19.288 F19.29 F19.90 F19.920 F19.921 F19.922 F19.929
F19.930 F19.931 F19.932 F19.939 F19.94 F19.950 F19.951
F19.959 F19.96 F19.97 F19.980 F19.981 F19.988 F19.99
F45.42 G89.4 G89.21 G89.22 G89.28 G89.29 O99.320
O99.321 O99.322 O99.323 O99.324 Z51.81 Z76.0 Z79.891
Z79.899

Links