Outpatient Hospitals, Physicians, and Independent Laboratories
RE: Policy on Qualitative Drug Screening
Effective beginning dates of service January 1, 2012, and thereafter, Medicaid will adopt the following policy on qualitative drug screening:
The following drug screens will be limited to one specimen every seven days per recipient, per provider (providers within a group are considered a single provider), and may not be billed in any combination: 80100, 80101, 80102, and 80104.
Example: A test that is done on Wednesday cannot be done again until the following Wednesday.
A qualitative drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used; however urine is the best specimen for broad qualitative screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants. Detection of a drug or its metabolite(s) in urine is evidence of prior use. It does not, by itself, indicate that the drug remains in the blood.
Current methods of drug analysis include chromatography, immunoassay, chemical (“spot”) tests, and spectrometry. Analysis is comparative, matching the properties or behavior of a substance with that of a valid reference compound (a laboratory must possess a valid reference agent for every substance that it identifies). Drugs or classes of drugs are commonly assayed by qualitative screen followed by confirmation with a second method.
Note: Medicaid will only reimburse one screen (whether the specimen is blood or urine) per recipient, per provider, per seven-day period.
Note: A recipient cannot be billed for panels within the specimen.
Drugs or classes of drugs that are commonly assayed by qualitative screen, followed by confirmation with a second method, include the following:
· Cocaine and Metabolites
· Tricyclic Antidepressants
The following CPT codes are applicable for services under the qualitative drug screening policy (maximum unit limitation per recipient, per provider, per seven-day week):
· 80100-Drug screen, qualitative; multiple drug classes, each procedure-1 unit per specimen
· 80101-Single drug class, each drug class-1 unit per specimen
· 80102-Drug confirmation, each procedure-1 unit per specimen
· 80104-Drug screen, qualitative; multiple drug classes other than chromatographic method-1 unit per specimen
Note: Use the appropriate chemistry code (82000 – 84999) for quantitation of drugs screened, and the appropriate therapeutic drug assay code (80150 – 80299) for therapeutic drug levels.
Drug Screening Test Frequency
Medicaid allows payment of a screening test frequency of once per every seven-day period.
Medicaid will cover medically necessary qualitative drug screens as follows:
1. Suspected drug overdose, and one or more of the following conditions:
· Unexplained coma;
· Unexplained altered mental status;
· Severe or unexplained cardiovascular instability (cardiotoxicity);
· Unexplained metabolic or respiratory acidosis;
· Unexplained head trauma with neurological signs and symptoms; and/or,
· Seizures with an undetermined history.
2. Beneficiary presents with clinical signs/symptoms of substance abuse.
3. High risk pregnancy only when the documented patient history demonstrates that the procedure is medically necessary. Medicaid does not consider a qualitative drug screen as a routine component of assessment.
4. EPSDT services only when the documented patient history demonstrates that the procedure is medically necessary. Medicaid does not consider a qualitative drug screen as a routine component of assessment.
Medicaid will not cover qualitative drug screens for the following:
· To screen for the same drug with both a blood and a urine specimen simultaneously.
· For medicolegal purposes, including those listed under ICD-9 code V70.4. (Blood-alcohol tests, paternity testing and blood-drug tests).
· For employment purposes (i.e., as a pre-requisite for employment or as a means for continuation of employment).
· For active treatment of substance abuse, including monitoring for compliance.
· As a component of routine physical/medical examination, including those for subpopulations listed under ICD-9 code V70.5. (Armed forces personnel, Inhabitants of institutions, Occupational health examinations, Pre-employment screening, preschool children, Prisoners, Prostitutes, Refugees, School children and Students).
· As a component of medical examination for administrative purposes, including those listed under ICD-9 code V70.3. (General medical examination for: admission to old age home, adoption, camp, driving license, immigration and naturalization, insurance certification, marriage, prison, school admission and sports competition).
Prior approval will not be required for qualitative drug screens.
The ordering/referring provider must retain documentation supporting medical necessity in the medical record. Documentation must include the medical necessity for performing the screen. All tests must be ordered in writing, and all drugs/drug classes to be screened must be indicated in the order. A copy of the lab results must be retained in the medical record.
If the provider rendering the service is other than the ordering/referring provider, the provider rendering the service must maintain hard copy documentation of the ordering/referring provider’s order for the test and the lab results. The order must include clinical indication/medical necessity in addition to all drugs/drug classes to be screened.
Documentation must be legible and available for review upon request.