2.0 HCPCS
Procedure codes
On or before December 31,
2015: G0431, G0434, G6030 - G6058
On
or after January 1, 2016, and before January 1, 2017:
G0477 - G0483
On
or after January 1, 2017: 80305 - 80307, G0480 - G0483
3.0 DESCRIPTION
Drug
testing may be performed with either a blood or urine sample. This
policy clarifies TRICARE coverage of drug testing and provides guidance
on the appropriate use and billing for these services, in accordance
with TRICARE statute and regulation.
4.0 POLICY
4.1 TRICARE covers medically necessary and appropriate
qualitative and quantitative drug testing.
4.2 Qualitative/presumptive drug testing (Healthcare
Common Procedure Code System (HCPCS) procedure codes G0431 and G0434 on
or before December 31, 2015; G0477-G0479
between January
1, 2016
, and December 31, 2016; and 80305-80307 on
or after January 1, 2017) may be cost-shared for patients
with any of the following:
4.2.1 An unreliable history.
4.2.2 Multiple drug ingestion.
4.2.3 Delirium or coma, or other unexplained altered
mental status.
4.2.4 Severe or unexplained cardiovascular
instability.
4.2.5 Unexplained metabolic or respiratory
acidosis.
4.2.6 Seizures with an undetermined
history.
4.2.7 For the diagnosis of a medical
condition where drug toxicity may be a contributing factor.
4.2.8 For monitoring patient compliance during active
treatment for substance abuse. (See
paragraph 5.0 for exclusions
for medico-legal purposes.)
4.3 In accordance with 10 USC 1079(h)(1), TRICARE
is required to reimburse like Medicare, where practicable.
4.3.1 TRICARE does not
recognize Current Procedural Terminology (CPT) procedure codes 80320-80377
for reimbursement at this time.
4.3.2 There may be rare instances where a patient
requires multiple, medically necessary screening tests for drugs
of abuse to be performed in a single day; the use of HCPCS procedure
codes G0431 and G0434 on a per patient encounter basis allows payment
to be made for this rare situation. Multiple claims for these codes
on the same date of service shall be evaluated by the contractor
for medical necessity.
4.4 Drug screening to identify specific drugs,
to indicate when antagonists may be used, or to provide quantitative
information regarding specific drugs may be cost-shared. Definitive
and quantitative drug testing (HCPCS procedure codes G6030-G6058 on
or before December 31, 2015, and G0480-G0483 on or after January
1, 2016) is covered when all of the following indications are met:
4.4.1 To verify and further analyze initial drug
testing;
4.4.2 When medically necessary and
appropriate; and
4.4.3 When the results will impact
the medical management of the patient.
4.5 Therapeutic drug assays (CPT procedure codes
80150-80299), performed to monitor clinical response to a known,
prescribed medication, are covered when medically necessary and
appropriate.
5.0
Exclusions
5.1 Drug screening using blood and urine simultaneously.
5.2 Drug screening for medico-legal purposes (i.e.,
court-ordered, forensic, criminal, social service agency investigations,
parents involved in legal cases), employment purposes (i.e., as
a prerequisite for employment or continuation of employment), or
for drug testing or compliance in school settings. These services
are not medically necessary.
5.3 Routine drug screening, except when permitted
by policy noted above (e.g., monitoring for patient compliance during
active treatment).
5.4 Other drug screening for purposes unrelated
to medical necessity, and for situations where drug testing will
not impact the medical management of the patient.