Procedure Codes and Description
Group 1 Codes:
G0477 DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES; ANY NUMBER OF DEVICES OR PROCEDURES, (E.G., IMMUNOASSAY) CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (E.G., DIPSTICKS, CUPS, CARDS, CARTRIDGES), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE
G0478 DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES; ANY NUMBER OF DEVICES OR PROCEDURES, (E.G., IMMUNOASSAY) READ BY INSTRUMENT-ASSISTED DIRECT OPTICAL OBSERVATION (E.G., DIPSTICKS, CUPS, CARDS, CARTRIDGES), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE
G0479 DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES; ANY NUMBER OF DEVICES OR PROCEDURES BY INSTRUMENTED CHEMISTRY ANALYZERS UTILIZING IMMUNOASSAY, ENZYME ASSAY, TOF, MALDI, LDTD, DESI, DART, GHPC, GC MASS SPECTROMETRY), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE
G0480 Drug test def 1-7 classes
G0481 Drug test def 8-14 classes
G0482 Drug test def 15-21 classes
G0483 Drug test def 22+ classes
Group 2 Paragraph: The following CPT codes are Non-Covered by Medicare
Group 2 Codes:
80300 Drug screen non tlc devices
80301 Drug screen class list a
80302 Drug screen prsmptv 1 class
80303 Drug screen one/mult class
80304 Drug screen one/mult class
80320 – 80377 Drug screen quantalcohols – Drug/substance nos 7/more
Coverage Indications, Limitations, and/or Medical Necessity
A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.
Common methods of drug analysis include chromatography, immunoassay, chemical (“spot”) tests, and spectrometry.
Analysis is comparative, matching the properties or behavior of a substance with that of a valid reference compound (a laboratory must possess a valid reference agent for every substance that it identifies). Drugs or classes of drugs are commonly assayed by qualitative/presumptive testing. A test may be followed by confirmation with a second method, only if there is a positive or negative inconsistent finding from the qualitative/presumptive test in the setting of a symptomatic patient, as described below.
Examples of drugs or classes of drugs that are commonly assayed by qualitative/presumptive tests, followed by confirmation with a second method, are: alcohols, amphetamines, barbiturates/sedatives, benzodiazepines, cocaine and metabolites, methadone, antihistamines, stimulants, opioid analgesics, salicylates, cardiovascular drugs, antipsychotics, cyclic antidepressants, and others. Focused drug screens, most commonly for illicit drug use, may be more useful clinically.
Indications:
A. Although technology has provided the ability to measure many toxins, most toxicological diagnoses and therapeutic decisions are made based on historical or clinical considerations:
Laboratory turnaround time can often be longer than the critical intervention time course of an overdose.
The cost and support of maintaining the instruments, staff training, and specialized labor involved in some analyses are prohibitive.
For many toxins there are no established cutoff levels of .toxicity, making interpretation of the results difficult.
Although comprehensive screening is unlikely to affect emergency management, the results may assist the admitting physicians in evaluating the patient if the diagnosis remains unclear. Screening panels should be used when the results will alter patient management or disposition.
B. A qualitative/presumptive drug test may be indicated for a variety of reasons including the following:
1. A symptomatic patient when the history is unreliable, when there has been a suspected multiple-drug ingestion, to determine the cause of delirium or coma, or for the identification of specific drugs that may indicate when antagonists may be used.
2. For monitoring patient compliance during active treatment for substance abuse or dependence.
3. To monitor for compliance/adherence to the treatment plan or illicit drug use in patients under treatment or seeking treatment for a chronic pain condition. The clinical utility of drug tests in the emergency setting may be limited because patient management decisions are unaffected, since most therapy for drug poisonings is symptom directed and supportive.
C. Medicare will consider performance of a qualitative/presumptive drug test reasonable and necessary when a patient presents with suspected drug overdose and one or more of the following conditions:
Unexplained coma
Unexplained altered mental status in the absence of a clinically defined toxic syndrome or toxidrome
Severe or unexplained cardiovascular instability (cardiotoxicity)
Unexplained metabolic or respiratory acidosis in the absence of a clinically defined toxic syndrome or toxidrome
Testing on neonates suspected of prenatal drug exposure
Seizures with an undetermined history
D. Medicare will consider performance of a qualitative/presumptive drug test reasonable and necessary when a patient presents with one or more of the following conditions:
For monitoring patient compliance during active treatment for substance abuse or dependence.
A drug screen is considered medically reasonable and necessary in patients on chronic opioid therapy:
– In whom illicit drug use, non-compliance or a significant pre-test probability of non-adherence to the prescribed drug regimen is suspected and documented in the medical record; and/or
– In those who are at high risk for medication abuse due to psychiatric issues, who have engaged in aberrant drug-related behaviors, or who have a history of substance abuse.
Medicare will consider performance of a drug test reasonable and necessary in patients with chronic pain to:
– determine the presence of other substances prior to initiating pharmacologic treatment
– detect the presence of illicit drugs
– monitor adherence to the plan of care
Drugs, or drug classes for which testing is performed, should reflect only those likely to be present, based on the patient’s medical history, current clinical presentation, and illicit drugs that are in common use. Drugs for which specimens are being tested must be indicated by the referring provider in a written order.
A drug test may be reasonable and necessary for patients with known substance abuse or dependence, only when the clinical presentation has changed unexpectedly and one of the above indications is met.
A drug test may be reasonable and necessary for patients with symptoms of schizophrenia suspected to be secondary to drug or substance intoxication.
Definitive drug testing is indicated when:
1. The results of the screen are presumptively positive.
2. Results of the screen are negative and this negative finding is inconsistent with the patient’s medical history.
3. This test may also be used, when the coverage criteria of the policy are met AND there is no presumptive test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids.
A positive screen often results in an inadequate result upon which to make a proper determination. A more specific method, such as gas or liquid chromatography coupled with mass spectrometry, may be needed in order to obtain a confirmed analytical result. In particular, screens are frequently inadequate for interpretation of opiate and benzodiazepine results and therefore; quantitative testing may be needed in these instances. Confirmation testing is usually not required for drugs like methadone, wherein false positive results are rare. However, factors such as cross-reactivity with other similar compounds or interfering substances in the specimen may affect test results. Confirmatory testing eliminates the risk of false positives. Also, eliminated by confirmation, is the risk of a “pill scraper” slipping through. Patients diverting their drug, attempt to cheat the test by scraping a bit of drug from a pill into their urine sample. It would screen positive, but there would be no metabolite upon confirmation. Frequent use of this code will be monitored for appropriateness.
Limitations:
It is considered not reasonable or necessary to test for the same drug with both a blood and a urine specimen simultaneously.
Drug screening for medico-legal purposes (e.g., court-ordered drug screening) or for employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment) are not covered.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
ICD-10 Codes that Support Medical Necessity
Group 1 Paragraph: For monitoring of patient compliance in a drug treatment program, use diagnosis code Z03.89 as the primary diagnosis and the specific drug dependence diagnosis as the secondary diagnosis.
For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence use diagnosis code Z79.891, suspected of abusing other illicit drugs, use diagnosis code Z79.899.
G0477, G0478, G0479, G0480, G0481, G0482, G0483
Diagnosis codes must be coded to the highest level of specificity.
For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.
ICD-10 CODE DESCRIPTION
E87.2 Acidosis
F11.20 Opioid dependence, uncomplicated
F18.10 Inhalant abuse, uncomplicated
F18.120 Inhalant abuse with intoxication, uncomplicated
F18.90 Inhalant use, unspecified, uncomplicated
F19.20 Other psychoactive substance dependence, uncomplicated
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.89 Other schizophrenia
F55.3 Abuse of steroids or hormones
F55.8 Abuse of other non-psychoactive substances
I45.81 Long QT syndrome
I47.2 Ventricular tachycardia
R40.0 Somnolence
R40.1 Stupor
R40.20 Unspecified coma
R40.2110 Coma scale, eyes open, never, unspecified time
R40.2111 Coma scale, eyes open, never, in the field [EMT or ambulance]
R40.2112 Coma scale, eyes open, never, at arrival to emergency department
R40.2113 Coma scale, eyes open, never, at hospital admission
R40.2114 Coma scale, eyes open, never, 24 hours or more after hospital admission
R40.2120 Coma scale, eyes open, to pain, unspecified time
R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance]
R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department
R40.2123 Coma scale, eyes open, to pain, at hospital admission
R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission
R40.2210 Coma scale, best verbal response, none, unspecified time
R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance]
R40.2212 Coma scale, best verbal response, none, at arrival to emergency department
R40.2213 Coma scale, best verbal response, none, at hospital admission
R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission
R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time
R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance]
R40.2222 Coma scale, best verbal response, incomprehensible words, at arrival to emergency department
R40.2223 Coma scale, best verbal response, incomprehensible words, at hospital admission
R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission
R40.2310 Coma scale, best motor response, none, unspecified time
R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance]
R40.2312 Coma scale, best motor response, none, at arrival to emergency department
R40.2313 Coma scale, best motor response, none, at hospital admission
R40.2314 Coma scale, best motor response, none, 24 hours or more after hospital admission
R40.2320 Coma scale, best motor response, extension, unspecified time
R40.2321 Coma scale, best motor response, extension, in the field [EMT or ambulance]
R40.2322 Coma scale, best motor response, extension, at arrival to emergency department
R40.2323 Coma scale, best motor response, extension, at hospital admission
R40.2324 Coma scale, best motor response, extension, 24 hours or more after hospital admission
R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time
R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance]
R40.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department
R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission
R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission
R41.0 Disorientation, unspecified
R41.82 Altered mental status, unspecified
R44.0 Auditory hallucinations
R44.2 Other hallucinations
R56.9 Unspecified convulsions
T39.011A Poisoning by aspirin, accidental (unintentional), initial encounter
T39.012A Poisoning by aspirin, intentional self-harm, initial encounter
T39.013A Poisoning by aspirin, assault, initial encounter
T39.014A Poisoning by aspirin, undetermined, initial encounter
T39.091A Poisoning by salicylates, accidental (unintentional), initial encounter
T39.092A Poisoning by salicylates, intentional self-harm, initial encounter
T39.093A Poisoning by salicylates, assault, initial encounter
T39.094A Poisoning by salicylates, undetermined, initial encounter
T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental (unintentional), initial encounter
T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter
T39.1X3A Poisoning by 4-Aminophenol derivatives, assault, initial encounter
T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial encounter
T39.2X1A Poisoning by pyrazolone derivatives, accidental (unintentional), initial encounter
T39.2X2A Poisoning by pyrazolone derivatives, intentional self-harm, initial encounter
T39.2X3A Poisoning by pyrazolone derivatives, assault, initial encounter
T39.2X4A Poisoning by pyrazolone derivatives, undetermined, initial encounter
T39.311A Poisoning by propionic acid derivatives, accidental (unintentional), initial encounter
T39.312A Poisoning by propionic acid derivatives, intentional self-harm, initial encounter
T39.313A Poisoning by propionic acid derivatives, assault, initial encounter
T39.314A Poisoning by propionic acid derivatives, undetermined, initial encounter
T39.391A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], accidental (unintentional), initial
encounter
T39.392A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], intentional self-harm, initial encounter
T39.393A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], assault, initial encounter
T39.394A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], undetermined, initial encounter
T40.0X1A Poisoning by opium, accidental (unintentional), initial encounter
T40.0X2A Poisoning by opium, intentional self-harm, initial encounter
T40.0X3A Poisoning by opium, assault, initial encounter
T40.0X4A Poisoning by opium, undetermined, initial encounter
T40.1X1A Poisoning by heroin, accidental (unintentional), initial encounter
T40.1X2A Poisoning by heroin, intentional self-harm, initial encounter
T40.1X3A Poisoning by heroin, assault, initial encounter
T40.1X4A Poisoning by heroin, undetermined, initial encounter
T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter
T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter
T40.2X3A Poisoning by other opioids, assault, initial encounter
T40.2X4A Poisoning by other opioids, undetermined, initial encounter
T40.3X1A Poisoning by methadone, accidental (unintentional), initial encounter
T40.3X2A Poisoning by methadone, intentional self-harm, initial encounter
T40.3X3A Poisoning by methadone, assault, initial encounter
T40.3X4A Poisoning by methadone, undetermined, initial encounter
T40.4X1A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter
T40.4X2A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter
T40.4X3A Poisoning by other synthetic narcotics, assault, initial encounter
