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.