2.0 HCPCS 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) 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) 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 codes G0431 and G0434 on a per patient encounter
basis allows payment to be made for this rare situation.
4.3.3 The contractor shall evaluate
multiple claims for these codes on the same date of service 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 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
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.