80363
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- All documentation must be maintained in the patient medical record, be legible, include patient identification and the identity of the physician or non-physician practitioner responsible for care, and be available to the contractor upon request.
- Medical record documentation maintained by the ordering/treating physician must indicate the medical necessity and clinical indication(s) that led to ordering the drug test and support the selected diagnosis and CPT/HCPCS code(s).
- All tests must be ordered in writing by the treating provider and the order must specify all drugs/drug classes to be tested; the physician’s order must include the clinical indication/medical necessity.
- If the performing provider is different from the ordering/referring physician, the performing provider must maintain hard copy documentation of lab results and copies of the ordering physician’s order for the drug test.
Key Coverage Criteria
- Urine, blood, or oral fluid specimens may be used for drug testing, with urine preferred for broad screening of common drugs.
- Medicare Part B will pay for drug screening services when all coverage criteria, limitations, and medical necessity requirements of LCD DL34645 are met.
- Claims for drug screening services are payable under Medicare Part B only in these places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center — freestanding (50), rural health clinic — freestanding (72), and independent laboratory (81).
- Presumptive (qualitative/IA) urine drug testing is covered when medically necessary to immediately determine the presence or absence of drugs or drug classes for immediate clinical management.
- Definitive (quantitative/confirmation) UDT using GC-MS or LC-MS/MS is covered when clinically indicated to identify specific drugs, metabolites, synthetic/analog drugs, or when presumptive testing is inadequate for patient management.
- Point-of-care testing (POCT) presumptive IA is covered when the clinician and beneficiary are co-located and immediate results are required for same-encounter management.
9 Active Policies
A56915 — Billing and Coding: Urine Drug Testing
J05
L34645 — Urine Drug Testing
J05
BCBSIL-MED207.154 — Drug Testing in Pain Management and Substance Use Disorder Treatment
BCBSMT-MED207.154 — Drug Testing in Pain Management and Substance Use Disorder Treatment
BCBSNM-MED207.154 — Drug Testing in Pain Management and Substance Use Disorder Treatment
Related Codes
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