February 06, 2018

The urine drug testing field has been described as a huge profit center (“liquid gold” were their actual words), and reports indicate a growing number of clinics run their own testing operations instead of farming them out to independent labs.[1] But the numbers don’t always add up . . . at least in Alabama.

Payors impose different requirements for medical necessity and frequency of urine drug testing. If you read through the BCBSAL and Medicare urine drug testing policies, it may seem the differences between the two policies are minor. However, these two payors differ on the frequency of monitoring screenings (after the initiation of treatment) that are considered medically necessary, as well as on their coverage policies for confirmatory (definitive) tests.[2]

The most notable coverage difference that we have seen between the two programs is one you can’t see on the face of the policies. Instead, it arises from the application of the confirmatory testing policies, specifically each payor’s interpretation of the word “test.” To illustrate, consider the G-codes for confirmatory/definitive drug testing in the G0480s series: G0480 (definitive drug test for 1-7 drug class(es)), G0481 (definitive drug test for 8-14 drug class(es)), G0482 (definitive drug test for 15-21 drug class(es)), and G0483 (definitive drug test for 22 or more drug class(es)). Medicare treats each G-code as a “test” for purposes of counting tests toward a coverage or benefit limit, even though each G-code may represent a multiple drug classes tested.[3] By contrast, it is our understanding from conversations with BCBSAL that they consider each drug or drug class to represent a “test” for coverage and benefit limits. Providers should exercise caution when counting “tests” toward benefit limits and should pay careful attention not only to each payor’s benefit limits, but also to their interpretation of “tests.” To the extent providers bill beyond the applicable test limit, the tests would likely be non-covered or result in an overpayment.

We chose to highlight this particular coverage policy difference between Medicare and BCBSAL because it is not readily apparent from a reading of the two policies. However, there are other nuanced aspects of payor policies on urine drug testing. Physicians and billing/coding personnel should consult the relevant payor billing guidelines, with the assistance of counsel as necessary, in order to determine coverage for a particular test or service.  

Read more in Outpatient Lab Issues, Article I - HOPD Reference Lab Arrangements

  [1]See, e.g. David Segal, In Pursuit of Liquid Gold, New York Times (December 27, 2017), https://www.nytimes.com/interactive/2017/12/27/business/urine-test-cost.html.
  [2]See BlueCross BlueShield of Alabama Policy No. 566, Drug Testing (last reviewed December 2016), available at https://providers.bcbsal.org/portal/documents/10226/1791629/Drug+Testing/1c67985a-0c5d-4be9-aa3c-c49677cf6a93?version=1.1; Local Coverage Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L35724), CMS.gov, https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35724&ver=41&CntrctrSelected=381*1&Cntrctr=381&name=&DocType=Active&s=34%7c48%7c53%7c58&bc=AggAAAQBAAAA&. 
 [3] 2017 Controlled Substance Monitoring and Drugs of Abuse Coding and Billing Guidelines (M00128 V5), Palmetto GBA, https://www.palmettogba.com/palmetto/providers.nsf/docscat/Providers~JM%20Part%20B~Browse%20by%20Topic~Lab~2017%20Controlled%20Substance%20Monitoring%20and%20Drugs%20of%20Abuse%20Coding%20and%20Billing%20Guidelines%20(M00128%20V5) (describing each G-code as a “service” and providing that providers may only perform and report one G-code per date of service).