For Dates of Service Before January 1, 2017

Testing for Drugs of Abuse

Covered Services

Providers are required to use HCPCS procedure codes G0477–G0483 when submitting claims for testing for drugs of abuse. The HCPCS code set G0477–G0483 consists of two primary categories of drug testing: presumptive and definitive. Presumptive drug tests are used to detect the presence or absence of a drug or drug class; they do not typically indicate a specific level of drug but rather give a positive or negative result. A presumptive drug test may be followed with a definitive drug test in order to identify specific drugs or metabolites. Definitive drug tests are qualitative or quantitative tests used to identify specific drugs, specific drug concentrations, and associated metabolites.

Presumptive Drug Tests

ForwardHealth covers medically necessary presumptive drug tests for the following clinical indications:

• Suspected drug overdose, unreliable medical history, and an acute medically necessary situation. Medically necessary situations include, but are not limited to, unexplained coma, unexplained altered mental status, severe or unexplained cardiovascular instability, undefined toxic syndrome, and seizures with an undetermined history.
• Monitoring of a member's compliance during treatment for substance abuse or dependence. This applies to testing during an initial assessment, as well as ongoing monitoring of drug and alcohol compliance. Decisions about which substances to screen for should be well documented and should be based on the following:
  • The member's history of past drug use or abuse, the results of any physical examinations, and any of the member's previous laboratory findings
  • The substance the member is suspected of misusing
  • The member's prescribed medication(s)
  • Substances that may present high risk for additive or synergistic interactions with the member's prescribed medication(s)
  • Local information about substances commonly abused and misused, such as input from the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network that compiles prevalence data on drug-related emergency department visits and deaths
• Monitoring of a member receiving COT. Decisions about which substances to screen for should be well documented and should be based on the following:
  • The member's history of past drug use or abuse, the results of any physical examinations, and any of the member's previous laboratory findings
  • The member's current treatment plan
  • The member's prescribed medication(s)
  • The member's risk assessment plan

Definitive Drug Tests

Definitive drug tests can be used to evaluate presumptive drug test results, which can minimize the potential for a clinician to rely on a false negative or false positive result. Definitive drug tests can also be used to guide treatment when it is necessary to identify a specific drug within a drug class or identify a specific concentration of a drug. A definitive drug test order must be medically necessary and reasonable. The order for a definitive drug test must describe the medical necessity for each drug class being tested. A member's self-report may reduce the need for a definitive drug test.

Definitive drug testing includes direct-to-definitive drug tests. Direct-to-definitive drug tests are tests that are used without first performing a presumptive drug test of the sample. Direct-to-definitive drug tests are used when presumptive drug tests do not adequately detect the substance or metabolite identified for testing. Presumptive drug tests are inadequate when the component for a particular drug class does not react sufficiently to the identified drug or drug metabolite within that drug class, resulting in a false negative. Synthetic opioids, some benzodiazepines, or other synthetic drugs may not be adequately detected by presumptive drug tests. Direct-to-definitive drug tests are only appropriate in rare circumstances.

ForwardHealth covers medically necessary definitive drug tests for members when at least one of the clinical indications for presumptive drug tests applies and when there is at least one of the following needs:

• A definitive concentration of a drug must be identified to guide treatment.
• A specific drug in a large family of drugs (e.g., benzodiazepines, barbiturates, and opiates) must be identified to guide treatment.
• A false result must be ruled out for a presumptive drug test that is inconsistent with a member's self-report, presentation, medical history, or current prescriptions.
• A specific substance or metabolite that is inadequately detected by presumptive drug testing (direct-to-definitive testing), as determined on a case-by-case basis in accordance with community standard guidelines set by the practice, must be identified.

Testing Frequency

Testing for drugs of abuse should not be performed more frequently than the standard of care for a particular clinical indication. The testing frequency must be medically necessary and documented in the member's medical record.

Acute Medical Testing

A single presumptive and/or definitive drug test is appropriate for any acute medical presentation.

Chronic Opioid Therapy

Providers are required to document the testing frequency and rationale for testing (including a validated risk assessment) for members receiving COT. The following testing frequencies are based on a member's risk for abuse:

• Members with low risk for abuse may be tested up to one to two times per year.
• Members with moderate risk for abuse may be tested up to one to two times every six months.
• Members with high risk for abuse may be tested up to one to three times every three months.

Selection of Drug/Drug Class for Testing

In all cases, providers should only test for drugs or drug classes likely to be present based on the member's medical history, current clinical presentation, and illicit drugs that are in common use. In other words, it is not medically necessary or reasonable to routinely test for substances (licit or illicit) that are not used in a member's treatment population or, in the instance of illicit drugs, in the community at large.

Procedure Codes

Providers are required to use HCPCS procedure codes G0477–G0483 when submitting claims for testing for drugs of abuse. Providers should use procedure codes G0477–G0479 when submitting claims for presumptive drug tests. Providers are required to select the appropriate code based on the type of presumptive drug test used.

When submitting claims for definitive drug tests, providers should use procedure codes G0480–G0483. Providers are required to select the appropriate code based on the number of drug classes for which definitive drug testing is medically necessary. Definitive drug testing for more than seven drug classes (using procedure codes G0481–G0483) is only appropriate in rare circumstances.

Only one of the three presumptive drug tests may be submitted per day, per member. Only one of the four definitive drug tests may be submitted per day, per member.

Claim Submission

Providers should use HCPCS Level II procedure codes and follow CMS guidance in the most recent CLFS Final Rule when submitting claims for drug testing to ForwardHealth. The prescribing/referring/ordering provider is required to be Medicaid-enrolled and to be indicated on the claim form.

Documentation Requirements

The member's medical record must contain documentation that fully supports the medical necessity for services rendered. This documentation includes, but is not limited to, relevant medical history, physical examination, risk assessment, and results of pertinent diagnostic tests or procedures. The medical record must include the following information:

• A signed and dated member-specific order for each ordered drug test that provides sufficient information to substantiate each testing panel component performed ("standing orders," "custom profiles," or "orders to conduct additional testing as needed" are insufficiently detailed and cannot be used to verify medical necessity)
• A copy of the test results
• Rationale for ordering a definitive drug test for each drug class tested
• If a direct-to-definitive drug test is ordered, documentation supporting the inadequacy of presumptive drug testing

If the provider of the service is not the prescribing/referring/ordering provider, the provider of the service is required to maintain documentation of the lab results and copies of the order for the drug test. The clinical indication/medical necessity for the test must be documented in either the order or the member's medical record.