Medical Billing and Coding Guidelines for Controlled Substance Monitoring and Drugs of Abuse in 2017

Medical Billing and Coding for Drugs of AbuseUrine drug testing (UDT) is an important tool in pain management. Clinical drug testing in pain management is used to detect prescribed, therapeutic drugs, prescription drugs of abuse, illicit drugs, and/or other substances. Accurate, complete, and legible documentation of the services provided is crucial for success with pain management medical billing. For appropriate reimbursement, claims should be coded in accordance with the latest industry standard coding guidelines.

In 2017, there are new CPT codes for presumptive urine drug tests. Definitive drug testing codes remain unchanged, meaning that they are the same as in 2016.

Presumptive Drug Testing Codes 2017 – Additions and Deletions

Effective January 1, 2017:

  • Three new codes replace CPT codes 80300-80304 that were used for non-Medicare payers in 2016
  • The 2016 HCPCS codes G0477-G0479 used for Medicare claims are deleted.

Three New CPT codes: 80305-80307

CPT code 80305 replaces codes 80300 and/or G0477

80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service.

Results are read by direct optical observation.

CPT code 80306 replaces codes 80300 and/or G0478

80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.

Results are read by direct optical observation assisted by an instrument.

CPT code 80307 replaces codes 80301-80304 and/or G0479

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, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service.

Results are obtained by instrumented chemistry analyzers.

Definitive (Qualitative or Quantitative) UDT Testing Codes

The four HCPCS codes for definitive UDT testing are: G0480, G0481, G0482, and G0483.

  1. G0480 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 and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed.
  2. G0481 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 and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed.
  3. G0482 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 and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed.)
  4. G0483 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 and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed.

Claim Submission for Controlled Substance and Drugs of Abuse Testing – Points to Note

  • Claims should be accompanied by supporting documentation showing a request from the treating physician asking for clinical drug screening and/or testing services.
  • The submitted medical record must support the use of the selected ICD-10-CM code(s)
  • Documentation maintained by the ordering physician/treating physician must indicate the medical necessity for performing a qualitative drug test.
  • The service reported on the claim must match the service ordered by the physician.
  • Incidental findings not ordered by the physician are not a covered service and will be denied.
  • Each code represents all drugs and all classes performed by the respective methodology and can be reported only once per date of service (DOS).
  • DOS refers to the date the specimen was collected and not when the test was run.
  • A maximum of one presumptive urine drug test may be submitted and paid per patient DOS.
  • A maximum of one definitive urine drug test may be submitted and paid per patient DOS.
  • Drug confirmation tests are not eligible to be separately reported under any procedure code, unlisted codes or otherwise.
  • Specimen validity testing is not eligible to be separately billed under any procedure codes.

In the light of these coding and regulatory changes, the support of an experienced pain management medical billing company can be invaluable to ensure accurate claim submission for controlled substance monitoring and drugs of abuse testing. The expert teams in established outsourcing companies keep track of changing documentation and coding guidelines and help physicians submit error-free claims to maximize reimbursement.