Effective Date:September 1, 2020

Updates Effective:June 7, 2021

Purpose:
This policy provides 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:
Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible (FIDE)-SNP

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.¹

• 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.¹

Policy:
Horizon NJ Health will consider for reimbursement one (1) unit of presumptive testing (CPT Codes 80305, 80306 or 80307) OR one (1) unit of definitive testing, limited to HCPCS code G0480 or G0659 per date of service. When both presumptive and definitive testing are performed on the same date of service, Horizon NJ Health will only consider for reimbursement the presumptive testing code.

Presumptive and definitive urine drug testing must adhere to Horizon New Jersey Health’s medical policy guidelines. Definitive testing should be based on the results of the initial presumptive screening. Individualized urine drug testing should be ordered based on the member’s specific needs. Therefore, generic standing orders or reflex testing will not be considered for reimbursement.

Individualized urine drug testing should be ordered based on the member’s specific needs. Therefore, generic standing orders or reflex testing will not be considered for reimbursement.

HCPCS codes G0481, G0482, and G0483 are not eligible for reimbursement. In accordance with CMS guidelines, Horizon NJ Health shall not reimburse for CPT codes 80320–80377..²

Although there is no absolute limitation for indicated testing, we reserve the right to ask for verification of testing. 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 “Procedure” section 4.

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.⁴

Procedure:

1. Horizon NJ Health will consider for reimbursement one (1) presumptive code OR one (1) definitive code per date of service. When both a presumptive and definitive code are submitted for the same date of service, only the presumptive code will be considered for reimbursement.

2. Horizon NJ Health will not consider for reimbursement HCPCS codes G0481, G0482 and G0483.

3. Horizon will not consider for reimbursement more than one (1) unit of presumptive testing or more than one (1) unit of definitive testing performed on the same date of service.

4. CPT codes 80320–80377 will not be considered for reimbursement, advising the provider to bill with the appropriate HCPCS code, as provided above.

5. 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(s)
   • Pertinent medical records (History and Physical with assessment and plan)

Resources:

1. American Society of Addiction Medicine, Consensus Statement, “Appropriate Use of Drug Testing in Clinical Addiction Medicine” April, 2017
   https://www.asam.org/docs/default-source/quality-science/appropriate_use_of_drug_testing_in_clinical-1-(7).pdf?sfvrsn=2

2. CMS PFS Relative Value Files
   https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files

3. CMS, Local Coverage Article: Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A56645)
   https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56645&ver=23&LCDId=35006&Date=&DocID=L35006&bc=iAAAABAAkAAA&

4. CMS Laboratory Documentation Requirements
   https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909221

Additional Resources:

1. CMS Local Coverage Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L35006)
   https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35006&ver=119&Date=&DocID=L35006&bc=iAAAABABAAAA&

2. CMS, MLN Matters Number: SE18001 Proper Coding for Specimen Validity Testing Billed in Combination with Drug Testing
   https://www.cms.gov/media/416286

3. American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

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

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

History: