Urine Drug Screening/Testing

Reimbursement Policy:
Urine Drug Screening/Testing

Effective Date:
November 30, 2013

Last Revised Date:
May 21, 2018

Purpose:
The purpose of this policy is to provide guidelines for the reimbursement of Urine Drug Screening/Testing. This policy applies to professional and laboratory providers.

Scope:
All products are included except:

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
  • Horizon BCBSNJ Medicare Advantage plans
  • Horizon NJ Health plans
  • Flex Link
  • ITS Home Par
  • ITS Host Medicare Advantage (PPO OON)
  • MPL
  • COB

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
In accordance with CMS guidelines, Horizon BCBSNJ shall not reimburse CPT codes 80320 - 80377 because of the potential for overpayment when billing for each individual drug test rather than a single code that pays the same amount regardless of the number of drugs that are being tested.

Horizon BCSNJ shall reimburse the appropriate HCPCS drug screening codes, including: 80305, 80306, 80307, G0480, G0481, G0482, G0483 and G0659.

The CPT codes and nomenclature used in this policy are subject to revision and/or change by the American Medical Association. In the event of such changes, this policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as this policy is reviewed and updated to reflect the new or amended coding.

The Clinical Laboratory Improvement Amendment (CLIA) of 1988 was established to ensure the accuracy and reliability of laboratory testing. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the CLIA. Labs performing such tests must have a CLIA certificate, with the exception of certain CLIA waived tests which include test systems cleared by the FDA for home use and those tests approved for waiver under certain CLIA criteria. Horizon BCBSNJ follows guidance from the FDA and CMS regarding which tests may be performed in labs without CLIA certification. Claims for CLIA-waived tests should be submitted with the QW modifier as appropriate.

Procedure:
CPT codes 80320 - 80377 will be denied advising the provider to bill with the appropriate HCPCS code, as provided above.

Horizon BCBSNJ will reimburse one unit of service for procedure codes 80305 - 80307, G0480 - G0483 and G0659 per patient encounter regardless of the number of drug classes tested or the number of units billed. These codes may not be billed together on the same CMS 1500.

Additional units will be considered for reimbursement upon appeal. The appeal must include all of the following documentation:

  • The written request for service or standing order dated within 30 days of the date of service
  • The specimen identification number
  • The date of receipt of the specimen by the servicing provider
  • The date of specimen collection and by whom it was collected
  • The means of identifying the source of the specimen
  • The name of each test performed, including confirmatory and adulteration tests, the date performed, and the results
  • The name and address of each recipient of test results and the date reported.

In instances where the provider is participating, there shall be no subscriber liability.

In instances where the provider is not participating, subscriber liability shall be up to billed charges.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or individual benefit
  • Provider participation agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
11/20/2013: Policy Approved
07/01/2016: Revised to update CPT Codes and HCPC Codes; included information on subscriber liability.
01/25/2017: Deleted codes G0477, G0478, G0479 and 80300- 80304 based on 2017 CMS new code update deleting these codes. Added procedure codes 80305 – 80307 and G0659 as eligible for reimbursement.
03/31/2017: Added CLIA statement.
5/21/2018: Added Horizon BCBSNJ Medciare Advantage plans to Scope exclusions.

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

Policy 074_v5.0_05212018