Policy Statement
Presumptive Testing
Presumptive drug tests must be reported using procedure codes 80305-80307. Reimbursement for procedure codes 80305-80307 is limited to one unit per day. Only one of the three 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 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, 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.
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
- Pass through billing
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.
References
- American Medical Association, Current Procedural Terminology (CPT®)
Cross References
- Medical Policy Lab 68 - Drug Testing for Substance Use and Pain Management
- Adm 105 – Bundling Edits
- Adm 107 – Non-Reimbursable Services
- Adm 129 – Correct Coding
