T50.996A — Underdosing of other drugs, medicaments and biological substances, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical necessity for each test must be documented in the patient's medical record as required by LCD L35006.
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include patient identification and dates of service.
- Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Urine drug testing (UDT) and drugs-of-abuse testing are covered when reasonable and necessary per LCD L35006 and ordered on an individual patient basis by the treating clinician with medical-record documentation of medical necessity.
- Patients with a documented diagnosis consistent with substance use disorder (SUD) may qualify for an exception to the standard presumptive UDT annual limits.
- Presumptive (qualitative) urine drug testing (UDT) is covered when medically necessary to determine presence or absence of drugs or drug classes and when immediate results are needed (point-of-care testing when patient and clinician are co-located).
- Definitive quantitative confirmation testing (GC-MS or LC-MS/MS) is covered when medically necessary to identify specific drugs or metabolites not adequately detected by presumptive testing, to distinguish specific drugs within a large drug family, or when a definitive concentration is needed to guide management.
- Reflex definitive testing by a reference laboratory is covered without an additional clinician order to verify a presumptive positive UDT or to confirm the absence of a prescribed medication when a laboratory presumptive test is negative.
- UDT (presumptive and/or definitive) is covered for symptomatic patients presenting with suspected substance toxicity, including coma, unexplained altered mental status (without a toxidrome), severe or unexplained cardiovascular instability, unexplained metabolic or respiratory acidosis, seizures of undetermined history, or when administration of a specific antagonist is considered.
2 Active Policies
A56645 — Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing
J12
L35006 — Controlled Substance Monitoring and Drugs of Abuse Testing
J12
Related Codes
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