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TRICARE Policy Manual 6010.60-M, April 1, 2015
Pathology And Laboratory
Chapter 6
Section 4.1
Drug Testing
Issue Date:  August 19, 2015
Authority:  10 USC 1079(h)(1); 32 CFR 199.4(c); 32 CFR 199.14
Copyright:  HCPCS Level I/CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-4, June 30, 2017
1.0  CPT Procedure Codes
80150 - 80299
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
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.
4.1  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.
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