Blue Cross and Blue Shield of New Mexico will continue to follow Medicare’s lead and zero-price the Current Procedural Terminology (CPT®) codes for drug testing (80300 – 80377, other than the presumptive codes listed below).
With a few exceptions, BCBSNM’s billing guidelines for urine drug testing are intended to be consistent with those established by CMS for safety, accuracy and quality of diagnostic testing and will make use of CPT codes 80305, 80306 and 80307 for presumptive testing and HCPCS codes G0480, G0481, G0482, G0483 or G0659 for definitive testing that CMS published for 2018 drug testing.
Physician-owned/operated laboratories will use G0659 (Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes) when performing urine drug testing using GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem).
CLIA Certification requirement
Facilities and private providers who perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988. Therefore, any provider who performs laboratory testing, including urine drug tests, must possess a valid a CLIA certificate for the type of testing performed.
CPT Codes for Qualitative Drug Screen (Presumptive Drug Testing)
Use 80305 for testing capable of being read by direct optical observation only. Test includes validity testing when performed and may be performed only once per date of service.
Use 80306 when test is read by instrument- assisted direct optical observation. Test includes validity testing when performed and may be performed only once per date of service.
Use 80307 when test is performed by instrumented chemistry analyzers (e.g. Immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, CHPC, GC mass spectrometry). Test includes validity testing when performed and may be performed only once per date of service.
Qualitative or presumptive drug screening must meet medical policy criteria, including appropriate medical record documentation.
All of these codes include any number of drug classes, devices or procedures. Only one of the presumptive codes may be billed per date of service.
Confirmation Drug Testing
Consistent with Medical Policy MED207.154, Drug confirmation (definitive testing) is indicated when the result of the drug screen is different than that suggested by the patient’s medical history, clinical presentation or patient’s own statement.1
NOTE: Saliva or oral swabs do not meet the medical policy for drug testing.
Definitive Drug Testing
All of these codes are tests utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS, (any type, single, or tandem) and LC/MS (any type, single, or tandem and excluding immunoassays (e.g. IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., Alcohol dehydrogenase)); qualitative or quantitative, all sources, including specimen validity testing. Only one of the definitive G codes may be billed per date of service.
- G0480 – 1-7 drug class(es), including metabolites
- G0481 – 8-14 drug class(es), including metabolites
- G0482 – 15-21 drug class(es), including metabolites
- G0483 – 22 or more drug class(es), including metabolites
REMINDER: Physician office laboratories will bill definitive testing using G0659, once per date of service.
Billing & Documentation Information & Requirements
BCBSNM does not allow Pass-Through Billing or Other Billing/Service Arrangements
- Pass-through billing occurs when a physician or other provider requests and bills for a service, but the service is not actually performed by that physician or provider.
- “Under arrangement” billing and other similar billing or service arrangements are not permitted by BCBSNM. Physician or other provider is not permitted to allow another entity or individual to bill or submit claims for reimbursement to BCBSNM under its Agreement (contract) for services. “Under arrangement” billing occurs when a physician or other provider renders services and a hospital or other entity bills for the services under its agreement with The Plan. Physician or other provider is not permitted to bill for services that are provided by another entity or provider.
All testing and services that share the same date of service for a patient must be billed on one claim. Split billing is a violation of network participating provider agreements.
BCBSNM may monitor the manner in which test codes are billed, including frequency of testing. Abusive billing, poor or no documentation to support the billing, including a lack of appropriate orders, may result in action taken against the provider’s network participation and/or 100% review of medical records for such claims submitted.
Documentation Requirements
The clinician’s documentation must be patient-specific and accurately reflect the need for each test ordered. Each drug or drug class being tested for must be indicated by the ordering clinician in a written order and documented in the patient’s medical record. As stated more fully in Medical Policy MED207.154:
Drugs or drug classes for which screening is performed should only reflect those likely to be present based on the patient’s medical history or current clinical presentation, and without duplication. Each drug or drug class being tested for must be indicated by the referring clinician in a written order and so reflected in the patient’s medical record. Additionally, the clinician’s documentation must be patient specific and accurately reflect the need for each test.
Orders
Orders for diagnostic tests, including laboratory tests, must be specific to both the patient and the need for the test requested. Panel testing is restricted to panels published in the current CPT manual. Orders must be signed and dated by the ordering health care professional. “Custom” panels are not specific to a particular patient and are not allowed. Further, the following are not reimbursable: Routine screenings, including quantitative (definitive) panels, performed as part of a clinician’s protocol for treatment, Standing orders which may result in testing that is not individualized and/or not is used in the management of the patient’s specific medical condition, Reflex (or automatic) testing is not acceptable and Validity testing, an internal process to affirm that the reported results are accurate and valid.
Claims that are accompanied by medical records that do not meet documentation requirements will not be reimbursed.
Reimbursement is subject to:
- Medical record documentation, including appropriately documented Orders
- Correct CPT/HCPCS coding
- Member Benefit and Eligibility
- Applicable BCBS Medical Policy(ies)
1Medical Policy MED207.154 states: Confirmatory testing is not appropriate for every specimen and should not be done routinely. This type of test should be performed in a setting of unexpected results and not on all specimens. The rationale for each confirmatory test must be supported by the ordering clinician’s documentation. The record must show that an inconsistent positive finding was noted on the qualitative test testing or that there was not an available qualitative test to evaluate the presence of semi-synthetic or synthetic opioid in a patient.
CPT copyright 2023 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.
The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. The fact that a service or treatment is described in this material, is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.