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.