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.