INSTRUCTIONS FOR USE
The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member specific benefit plan document or Certificate of Coverage, the member specific benefit plan document or Certificate of Coverage will govern.
UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
APPLICABLE LINES OF BUSINESS/PRODUCTS
This policy applies to Oxford Commercial plan membership.
APPLICATION
This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.
OVERVIEW
This policy defines the daily limit for presumptive Drug testing codes (80305, 80306, 80307 and H0003) and definitive drug testing codes (0006U, 0007U, 0011U, 0020U, 0082U, G0480, G0481, G0482, G0483, and G0659) and addresses Specimen Validity Testing.
All services described in this policy may be subject to additional Oxford Reimbursement Policies.
REIMBURSEMENT GUIDELINES
This policy enforces the code description for presumptive and definitive drug testing in that the service should be reported once per day and it includes Specimen Validity Testing.
Clinical drug testing is used in pain management and in substance abuse screening and treatment programs. The testing may be used to detect prescribed, therapeutic drugs, prescription drugs of abuse, illicit drugs, and/or other substances such as nicotine.
Presumptive drug testing, also known as drug screening, is used when necessary to determine the presence or absence of drugs or a Drug Class. Results are expressed as negative or positive. The methodology is considered when coding presumptive procedures. Per Current Procedural Terminology (CPT®) guidelines each presumptive drug testing code represents all drug and Drug Class tests performed by the respective methodology per date of service. The test is a single per patient service that should only be reported once irrespective of the number of Drug Class procedures or results on any date of service.
Definitive drug testing, also known as confirmation testing, is used when it is necessary to identify specific medications, illicit substances and metabolites. Definitive urine drug test (UDT) reports the results of drugs absent or present in concentrations of ng/ml. Definitive drug testing is qualitative or quantitative to identify possible use or nonuse of a drug. These tests identify specific drugs and associated metabolites. A presumptive drug test is not required to be provided prior to a definitive drug test. Consistent with CMS, definitive drug testing CPT codes 80320-80377 are considered non-reimbursable and the appropriate HCPCS G0480-G0483 and G0659 should be reported. The HCPCS codes describe a per-day service that represents the total number of different Drug Classes performed. When applicable, Proprietary Laboratory Analysis CPT code 0006U, 0007U, 0011U, 0020U, or 0082U may be reported and are considered under the policy guidelines pertaining to definitive drug testing.
Some examples of drugs or a Drug Class that are commonly assayed by presumptive tests, followed by definitive testing are: alcohols, amphetamines, barbiturates/sedatives, benzodiazepines, cocaine and metabolites, methadone, antihistamines, stimulants, opioid analgesics, salicylates, cardiovascular drugs, antipsychotics, and cyclic antidepressants.
In accordance with the code descriptions and the CPT and CMS guidelines, Oxford will only allow one drug test within the presumptive Drug Class and one drug test within the definitive Drug Class per date of service by the same or different provider.
Specimen Validity Testing to assure that a specimen has not been compromised or that a test has not been adulterated may be required. However, Specimen Validity Testing is included in the presumptive and definitive drug
testing CPT and HCPCS code descriptions and is considered a quality control which is an integral part of the collection process and is not separately reimbursable. Oxford will deny Specimen Validity Testing when performed on the same date of service as a presumptive and/or definitive drug test by the same or different provider. A modifier may be
appropriate when a service commonly used for Specimen Validity Testing is performed distinctly separate from the drug test service and the documentation supports the service was not related to the drug testing.
Drug testing services that are determined to be court ordered and/or funded by a county, state or federal agency will continue to be denied. For additional information, refer to the Reimbursement Policy titled Services and Modifiers Not Reimbursable to Healthcare Professionals.
Drug Class: A group of drugs that have the same chemical structure, work in the same way and/or are used for the same purpose.
Proprietary Laboratory Analysis (PLA) Codes: Describe proprietary clinical laboratory analysis and can be provided either by a single (“sole-source”) laboratory or licensed or marketed to multiple providing laboratories (e.g., cleared or approved by the Food and Drug Administration [FDA]). These codes include advanced diagnostic laboratory
tests (ADLTs) and clinical diagnostic laboratory tests (CDLTs) as defined under the Protecting Access to Medicare Act (PAMA) of 2014.
Specimen Validity Testing: Generally pertains to urine specimen testing to ensure that the sample has not been adulterated or substituted. It may be applicable to other types of specimens.
APPLICABLE CODES
The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.
CPT/HCPCS Code Description
Definitive Drug Testing
0006U Prescription drug monitoring, 120 or more drugs and substances, definitive tandem
mass spectrometry with chromatography, urine, qualitative report of presence
(including quantitative levels, when detected) or absence of each drug or substance
with description and severity of potential interactions, with identified substances, per
date of service
0007U Drug test(s), presumptive, with definitive confirmation of positive results, any
number of drug classes, urine, includes specimen verification including DNA
authentication in comparison to buccal DNA, per date of service
0011U Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, using oral
fluid, reported as a comparison to an estimated steady-state range, per date of
service including all drug compounds and metabolites
0020U Drug test(s), presumptive, with definitive confirmation of positive results, any
number of drug classes, urine, with specimen verification including DNA
authentication in comparison to buccal DNA, per date of service
0082U Drug test(s), definitive, 90 or more drugs or substances, definitive chromatography
with mass spectrometry, and presumptive, any number of drug classes, by
instrument chemistry analyzer (utilizing immunoassay), urine, report of presence or
absence of each drug, drug metabolite or substance with description and severity of
significant interactions per date of service
G0480 Drug test(s), definitive, utilizing (1) 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)), (2)
stable isotope or other universally recognized internal standards in all samples (e.g.,
to control for matrix effects, interferences and variations in signal strength), and (3)
method or drug-specific calibration and matrix-matched quality control material
(e.g., to control for instrument variations and mass spectral drift); qualitative or
quantitative, all sources, includes specimen validity testing, per day; 1-7 drug
class(es), including metabolite(s) if performed
G0481 Drug test(s), definitive, utilizing (1) 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)), (2)
stable isotope or other universally recognized internal standards in all samples (e.g.,
to control for matrix effects, interferences and variations in signal strength), and (3)
method or drug-specific calibration and matrix-matched quality control material
(e.g., to control for instrument variations and mass spectral drift); qualitative or
quantitative, all sources, includes specimen validity testing, per day; 8-14 drug
class(es), including metabolite(s) if performed
CPT/HCPCS Code Description
Definitive Drug Testing
G0482 Drug test(s), definitive, utilizing (1) 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)), (2)
stable isotope or other universally recognized internal standards in all samples (e.g.,
to control for matrix effects, interferences and variations in signal strength), and (3)
method or drug-specific calibration and matrix-matched quality control material
(e.g., to control for instrument variations and mass spectral drift); qualitative or
quantitative, all sources, includes specimen validity testing, per day; 15-21 drug
class(es), including metabolite(s) if performed
G0483 Drug test(s), definitive, utilizing (1) 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)), (2)
stable isotope or other universally recognized internal standards in all samples (e.g.,
to control for matrix effects, interferences and variations in signal strength), and (3)
method or drug-specific calibration and matrix-matched quality control material
(e.g., to control for instrument variations and mass spectral drift); qualitative or
quantitative, all sources, includes specimen validity testing, per day; 22 or more drug
class(es), including metabolite(s) if performed
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 Presumptive Drug Testing
80305 Drug test(s), presumptive, any number of drug classes, any number of devices or
procedures; capable of being read by direct optical observation only (e.g., utilizing
immunoassay [e.g., dipsticks, cups, cards, or cartridges]), includes sample validation
when performed, per date of service
80306 Drug test(s), presumptive, any number of drug classes, any number of devices or
procedures; read by instrument assisted direct optical observation (e.g., utilizing
immunoassay [e.g., dipsticks, cups, cards, or cartridges]), includes sample validation
when performed, per date of service
80307 Drug test(s), presumptive, any number of drug classes, any number of devices or
procedures; by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g.,
EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and
mass spectrometry either with or without chromatography, (e.g., DART, DESI, GCMS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation
when performed, per date of service
H0003 Alcohol and/or drug screening; laboratory analysis of specimens for presence of
alcohol and/or drugs
Specimen Validity Testing
81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones,
leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these
constituents; non-automated, with microscopy
81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones,
leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these
constituents; automated, with microscopy
81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones,
leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these
constituents; non-automated, without microscopy
81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones,
leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these
constituents; automated, without microscopy
81005 Urinalysis; qualitative or semiquantitative, except immunoassays
82542 Column chromatography, includes mass spectrometry, if performed (e.g., HPLC, LC,
LC/MS, LC/MS-MS, GC, GC/MS-MS, GC/MS, HPLC/MS), non-drug analyte(s) not
elsewhere specified, qualitative or quantitative, each specimen
82570 Creatinine; other source
83516 Immunoassay for analyte other than infectious agent antibody or infectious agent
antigen; qualitative or semiquantitative, multiple step method
83518 Immunoassay for analyte other than infectious agent antibody or infectious agent
antigen; qualitative or semiquantitative, single step method (e.g., reagent strip)
83519 Immunoassay for analyte other than infectious agent antibody or infectious agent
antigen; quantitative, by radioimmunoassay (e.g., RIA)
83520 Immunoassay for analyte other than infectious agent antibody or infectious agent
antigen; quantitative, not otherwise specified
83789 Mass spectrometry and tandem mass spectrometry (e.g., MS, MS/MS, MALDI, MSTOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative,
each specimen
83986 pH; body fluid, not otherwise specified
84156 Protein, total, except by refractometry; urine
84311 Spectrophotometry, analyte not elsewhere specified
QUESTIONS AND ANSWERS
1
Q: Will Oxford reimburse more than one presumptive and/or one definitive drug test on the same date of
service if a modifier is appended?
A:
No, each of the presumptive and definitive drug codes define a single manual or automated laboratory
service that is reported once per day, per patient, irrespective of the number of Drug Classes, sample
validations, or Specimen Validity Tests performed related to that service on any date of service. In
accordance with the CPT and CMS guidelines Oxford will not reimburse more than one presumptive
and/or one definitive drug test per day regardless of the number of billing providers.
2
Q: Will Oxford consider separate reimbursement for laboratory service (e.g., urinalysis for urinary tract
infection) performed on the same day as a drug screening test?
A:
Yes, Oxford will consider separate reimbursement of laboratory services that are appended with an
appropriate modifier to identify the test was distinctly separate and not related to the drug testing as a
Specimen Validity Test and the modifier was appropriately reported.
3
Q: What is the difference between Presumptive and Definitive testing?
A:
A presumptive test is one used to identify possible use or non-use of a drug or Drug Class. Presumptive
tests are not definitive. They only screen for the presence of a compound. A definitive or confirmation
test is one that uses instrument analysis to positively identify the presence or quantity of a drug.
Reference:
https://www.uhcprovider.com/content/dam/provider/docs/public/policies/oxford/drug-testing-ohp.pdf
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