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.

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

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

Procedure Codes

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

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

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

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

Individual drug tests are considered not medically necessary.

Procedure Codes

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

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    

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