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Urine Drug Screening/Testing

Reimbursement Policy:
Urine Drug Screening/Testing

Effective Date:
November 30, 2013

Last Revised Date:
September 28, 2020

Purpose:
To provide guidelines for the reimbursement of urine drug testing. This policy applies to participating and non-participating professional and laboratory providers for the following procedure codes: 80305, 80306, 80307, 80320-80377, G0480, G0481, G0482, G0483, and G0659.

Scope:
All products are included except:

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

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

Definitions
Presumptive drug testing: Testing performed using a method with lower sensitivity and/or specificity, which establishes preliminary evidence regarding the absence or presence of drugs or metabolites in a sample.

Definitive drug testing: Testing performed using a method with high sensitivity and specificity that is able to identify specific drugs, their metabolites, and/or drug quantities.

Policy:
Horizon BCBSNJ shall consider for reimbursement one (1) unit of presumptive testing (CPT Codes 80305, 80306 or 80307) and one (1) unit of definitive testing, limited to HCPCS code G0480 or G0659, when performed on the same date of service.

Presumptive and definitive urine drug testing must adhere to Horizon BCBSNJ’s medical policy guidelines. Definitive testing should be ordered based on the results of the initial presumptive screening. Urine drug testing should be ordered on an individualized basis in accordance with the member’s specific needs. Therefore, generic standing orders or reflex testing that are applied in all cases to all members will not be considered for reimbursement.

HCPCS codes G0481, G0482, and G0483 are not eligible for reimbursement. In accordance with CMS guidelines, Horizon BCBSNJ shall not reimburse for CPT codes 80320–80377.

Although there is no absolute limitation for indicated testing, we reserve the right to ask for documentation of the need for the amount of testing ordered. Testing of more than twenty four (24) units during a treatment year, regardless of the type of testing, requires submission of additional documentation.3 Documentation requirements are listed below in the "Procedure" section.

Urine drug testing must be ordered by a licensed practitioner such as a physician or an advanced practitioner (Physician Assistant or Nurse Practitioner) directly involved in care management of the member. Only testing ordered by these providers will be eligible for reimbursement.

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, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

The Clinical Laboratory Improvement Amendment of 1988 (CLIA) 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 when appropriate.

Procedure:
Horizon BCBSNJ shall consider for reimbursement one (1) unit for CPT codes 80305-80307 and one (1) unit of HCPCS code G0480 or G0659 per member, per date of service, subject to the limitations noted above. HCPCS codes G0481, G0482 and G0483 are not eligible for reimbursement. Horizon BCBSNJ shall not reimburse for more than one (1) unit of presumptive testing or more than one (1) unit of definitive testing performed on the same date of service.

CPT codes 80320–80377 shall be denied, advising the provider to bill with the appropriate HCPCS code, as provided above.

Additional units will be considered for reimbursement upon receipt of the following documentation:

  • Signed requisition form from the ordering provider. The requisition form must include:
    • A complete list of the drug class(es) being tested
    • Both the identity of the member and the provider
    • The provider credentials including the NPI number and a legible signature
    • The date and time the sample was collected and/or received at the laboratory
    • Primary diagnosis and/or appropriate ICD-10 code(2)
  • Pertinent medical records (History and Physical with assessment and plan)

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.

Resources:

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.
09/28/2020: Revised scope to include Medicare Advantage products. Revised content to allow 1 presumptive and 1 definitive urine drug test on a date of service.

Policy 074_v6.0_09282020