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Update: Urine Drug Testing in Pain Management and Substance Abuse Treatment Setting medical policy revision

This is an update to a news item posted on August 15, 2014.

Three diagnosis codes have been removed from the claim processing logic in section 1 below for services provided on and after November 13, 2014. Claims that include the CPT® codes listed will NOT be denied when submitted with diagnosis codes V20.2, V20.31 or V20.32.

  • Claims that include one unit per day of any of the CPT codes listed in section 1 when billed with diagnosis codes V20.2, V20.31 or V20.32 will not require a review to determine appropriateness of the services.
  • Claims that include two or more units per day of any of the CPT codes listed in section 1 when billed with diagnosis codes V20.2, V20.31 or V20.32 will pend while information is requested/reviewed to determine appropriateness of the services.

Horizon Blue Cross Blue Shield of New Jersey has revised our medical policy, Urine Drug Testing in Pain Management and Substance Abuse Treatment Setting, which will change the way we consider claims for urine drug testing beginning November 13, 2014.

Claims submitted for services provided on and after November 13, 2014 will be processed according to the following.

  1. Based on our revised medical policy, Horizon BCBSNJ will:

    Allow one unit per day using any of the CPT codes listed below when billed with a diagnosis code(s) other than one of those listed below.

    Pend claims that include two or more units per day using any of the CPT codes listed below when billed with a diagnosis code other than one of those listed below.  Claims will pend while information is requested/reviewed to determine appropriateness of the services in question.

    Deny any of the below-listed CPT codes when billed with one of the diagnosis codes listed below.

    CPT codes:
    80102, 80103, 80152, 80154, 80160, 80166, 80174, 80182, 80184, 80188, 82055, 82145, 82205, 82397, 82491, 82492, 83789, 82520, 82541, 82542, 82544, 82646, 83788, 83789, 83805, 83840, 83925, 83992 or 84311.

    Diagnosis codes:
    V25.01, V25.02, V25.03, V25.04, V25.09, V26.31, V26.32, V26.33, V26.34, V26.35, V26.39, V26.41, V26.42, V26.49, V61.8, V65.11, V65.19, V65.3, V65.40, V65.41, V65.43, V65.44, V65.45, V65.46, V65.49, V70.0, V72.60, V72.62 or V72.84.
  2. A monthly maximum of 4 units (1 unit/service per day up to 4 per month) will apply to HCPCS/CPT codes listed below.  Claims that exceed this maximum will pend while information is requested/reviewed to determine appropriateness of the services in question.

    G0431, G0434, 80102 or 80103.
  3. A monthly maximum of 3 units (1 unit/service per day up to 3 per month) will apply to the CPT codes listed below.  Claims that exceed this maximum will pend while information is requested/reviewed to determine appropriateness of the services in question.

    80152, 80154, 80160, 80166, 80174, 80182, 80184, 80188, 82055, 82145, 82205, 82397, 82491, 82492, 82520, 82541, 82542, 82544, 82646, 83788, 83789, 83805, 83840, 83925, 83992 or 84311. 
  4. HCPCS code G0434 and/or CPT code 82055 when billed in an office setting will be denied if not appropriately appended with modifier QW. 
  5. The following codes will be denied when billed in an office setting (regardless of modifier):

    G0431, 80152, 80154, 80160, 80166, 80174, 80182, 80184, 80188, 82145, 82397, 82491, 82492, 83789, 82520, 82541, 82542, 82544, 82646, 83788, 83789, 83805, 83840, 83925, 83992 or 84311. 
  6. Upon receipt of quantitative testing codes (see below) our system will search claim history for a related qualitative testing code (see below) provided to the patient in question within a date span of no more than seven days.

    A quantitative code will be denied if there is no supporting qualitative code in claim history within a seven-day span.

    Claims will deny if the date span between a quantitative testing code and the related qualitative testing code is greater than seven days.

    Quantitative testing codes:
    80152, 80154, 80160, 80166, 80174, 80182, 80184, 80188, 82055, 82145, 82205, 82397, 82491, 82492, 83789, 82520, 82541, 82542, 82544, 82646, 83788, 83789, 83805, 83840, 83925, 83992 or 84311.

    Qualitative testing codes:
    G0431, G0434 or 80103.

The guidelines of our revised medical policy, Urine Drug Testing in Pain Management and Substance Abuse Treatment Setting, are aligned with nationally recognized clinical criteria, current industry standards and American Society of Interventional Pain Physicians (ASIPP) guidelines.  The changes announced here do not impact, cancel or postpone the policy changes announced on June 3, 2014 that will be effective September 3, 2014.

This medical policy is available in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after November 13, 2014.

The information conveyed here is not a guarantee of payment.  Claim processing and reimbursement is subject to all member eligibility and member/group benefit limitations and exclusions.

CPT® is a registered mark of the American Medical Association.

Published on: November 13, 2014, 09:00 a.m. ET
Last updated on: November 24, 2020, 23:15 p.m. ET