L30574-LCD

Automated World Health

Local Coverage Determination (LCD) for Qualitative Drug Screening (L30574)

Contractor Information

Contractor Name First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L30574

LCD Title Qualitative Drug Screening

Contractor's Determination Number G0431

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 01/25/2010

Original Determination Ending Date

Revision Effective Date

For services performed on or after 02/13/2011

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f) (1) (A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1 §130.6 Change Request 6852, transmittal 653, dated March 19, 2010

Change Request 6974, transmittal 1992, dated June 25, 2010 Indications and Limitations of Coverage and/or Medical Necessity

A qualitative drug screen reports the presence of a drug in a blood or urine specimen. A blood or urine sample may be used. Urine is usually the preferred specimen type due to its sensitivity to many common drugs compared to blood specimens. A qualitative drug screen may be indicated when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the identification of specific drugs, and to indicate when antagonists may be used.

Indications

Medicare will consider performance of a qualitative drug screen (HCPCS codes G0431/G0434) medically reasonable and necessary for the following:

When the patient presents with suspected drug overdose or suspected drug misuse and one or more of the following indications:

• Unreliable patient history

• Multiple drug ingestions

• Unexplained delirium or 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

• Suspected history of substance abuse

• Seizures with an undetermined history

OR for one of the following indications:

• The management of a patient under treatment for substance abuse when there is suspicion of continued substance abuse

• The management of a patient with chronic pain in which there is a significant pre-test probability of non- adherence to the prescribed drug regimen as documented in the patient’s medical record

• The management of patients with chronic pain in a designated pain management clinic where this select population has a significant pretest probability of drug interactions and side effects

Limitations

Medicare will consider the performance of a qualitative drug screen not medically reasonable and necessary for the following:

• Simultaneous blood and urine specimen screening

• Medicolegal purposes (i.e., court-ordered drug screening, forensic examinations)

• Employment or recreational purposes

• Routine screening performed as part of a physician’s protocol for treatment in absence of any of the above indications

Routine urinalysis/urine creatinine performed on the same date of service/claim for the purpose of validating the urine specimen is considered screening. There is no screening benefit for routine urinalysis or urine creatinine, therefore, both will be denied when performed on the same date of service as the qualitative drug screen.

For management of patients under treatment of substance abuse or management of patients with chronic pain, point of service qualitative urine drug screen is the most frequently utilized testing. This testing is described by G0434 and is billed one unit per patient encounter.

Coding Information

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.

999x Not Applicable

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.

99999 Not Applicable

CPT/HCPCS Codes

NOTE: Effective January 1, 2011, based on the 2011 HCPCS Update, the descriptor for HCPCS code G0431 was revised to read: “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.”

80102 DRUG CONFIRMATION, EACH PROCEDURE

G0431 DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES BY HIGH COMPLEXITY TEST METHOD (E.G., IMMUNOASSAY, ENZYME ASSAY), PER PATIENT ENCOUNTER

G0434 DRUG SCREEN, OTHER THAN CHROMATOGRAPHIC; ANY NUMBER OF DRUG CLASSES, BY CLIA WAIVED TEST OR MODERATE COMPLEXITY TEST, PER PATIENT ENCOUNTER

ICD-9 Codes that Support Medical Necessity

276.2 ACIDOSIS

304.90 UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED USE

345.10 GENERALIZED CONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY

345.11 GENERALIZED CONVULSIVE EPILEPSY WITH INTRACTABLE EPILEPSY

345.3 GRAND MAL STATUS EPILEPTIC

345.90 EPILEPSY UNSPECIFIED WITHOUT INTRACTABLE EPILEPSY

345.91 EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY

426.10 ATRIOVENTRICULAR BLOCK UNSPECIFIED

426.11 FIRST DEGREE ATRIOVENTRICULAR BLOCK

426.12 MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK

426.13 OTHER SECOND DEGREE ATRIOVENTRICULAR BLOCK

426.82 LONG QT SYNDROME

427.1 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

427.2 PAROXYSMAL VENTRICULAR TACHYCARDIA

518.81 ACUTE RESPIRATORY FAILURE

780.01 COMA

780.09 ALTERATION OF CONSCIOUSNESS OTHER

780.39 OTHER CONVULSIONS

963.0 POISONING BY ANTIALLERGIC AND ANTIEMETIC DRUGS

965.1 POISONING BY OPIUM (ALKALOIDS) UNSPECIFIED

965.2 POISONING BY HEROIN

965.3 POISONING BY METHADONE

965.09 POISONING BY OTHER OPIATES AND RELATED NARCOTICS

965.1 POISONING BY SALICYLATES

965.4 POISONING BY AROMATIC ANALGESICS NOT ELSEWHERE CLASSIFIED

965.5 POISONING BY PYRAZOLE DERIVATIVES

965.61 POISONING BY PROPIONIC ACID DERIVATIVES

966.1 POISONING BY HYDANTOIN DERIVATIVES

967.1 POISONING BY BARBITURATES

967.2 POISONING BY CHLORAL HYDRATE GROUP

967.3 POISONING BY PARALDEHYDE

967.4 POISONING BY BROMINE COMPOUNDS

967.5 POISONING BY METHAQUALONE COMPOUNDS

967.6 POISONING BY GLUTETHIMIDE GROUP

967.7 POISONING BY MIXED SEDATIVES NOT ELSEWHERE CLASSIFIED

967.8 POISONING BY OTHER SEDATIVES AND HYPNOTICS

967.9 POISONING BY UNSPECIFIED SEDATIVE OR HYPNOTIC

969.1 - 969.09 opens in new window

POISONING BY ANTIDEPRESSANT, UNSPECIFIED - POISONING BY OTHER ANTIDEPRESSANTS

969.2 POISONING BY PHENOTHIAZINE-BASED TRANQUILIZERS

969.3 POISONING BY BUTYROPHENONE-BASED TRANQUILIZERS

969.4 POISONING BY OTHER ANTIPSYCHOTICS NEUROLEPTICS AND MAJOR TRANQUILIZERS

969.5 POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS

969.6 POISONING BY OTHER TRANQUILIZERS

969.7 POISONING BY PSYCHODYSLEPTICS (HALLUCINOGENS)

969.70 - 969.79 opens in new window

POISONING BY PSYCHOSTIMULANT, UNSPECIFIED - POISONING BY OTHER PSYCHOSTIMULANTS

969.8 POISONING BY OTHER SPECIFIED PSYCHOTROPIC AGENTS

969.9 POISONING BY UNSPECIFIED PSYCHOTROPIC AGENT

970.81 - 970.89 opens in new window

POISONING BY COCAINE - POISONING BY OTHER CENTRAL NERVOUS SYSTEM STIMULANTS

972.1 POISONING BY CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION

977.9 POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE

V15.81* PERSONAL HISTORY OF NONCOMPLIANCE WITH MEDICAL TREATMENT PRESENTING HAZARDS TO HEALTH

V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V71.09 OBSERVATION OF OTHER SUSPECTED MENTAL CONDITION

* Although designated by the American Medical Association (AMA) as supplementary codes, for the purposes of this LCD, FCSO Medicare will not require a primary ICD-9-CM code when using V15.81 or V58.69 to bill for approved indications.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD in the “indications and limitations of coverage” section. Documentation may include, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The ordering /referring physician must indicate the medical necessity for performing a qualitative drug screen in the medical documentation. All tests must be ordered in writing by a treating/referring provider and all drugs/drug classes to be screened must be indicated in the order. If office based testing, multiple drug class procedures versus each single drug class method should be clearly documented. (See Coding Guidelines)

When the qualitative drug screen is performed for the management of patients receiving active treatment for substance abuse, the medical record should reflect the need for the tests as part of the plan of care for the patient. Additionally, a copy of the lab results should be maintained in the medical records.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

It is not expected that a qualitative drug screen will be used as a prerequisite to a physician’s routine care and treatment plan. The reason for the qualitative drug screening must be documented in the evaluation and management of the patient.

Sources of Information and Basis for Decision

CDC Congressional Testimony. March 12, 2008. United States Senate Subcommittee on Crime & Drugs. Committee on the Judiciary and the Caucus on International Narcotics Control. 2009; Vol.58: 42

Department of Health and Human Services. Morbidity and Mortality Weekly Report. Overdose deaths involving prescription opioids among Medicaid enrollees –Washington, 2004-2007. Available at http://www.cdc.gov/mmwr.

Federation of State Medical Boards of the United States. Model policy for the use of controlled substances for the treatment of pain. Available at http://www.fsmb.org/grpol_policydocs.html.

Gourlay, DL, Caplan, YH, et al. Urine Drug Testing in Clinical Practice (2006 edition) Educational activity sponsored by California Academy of Family Physicians.

http://www.toxicologyunit.com/drug_screen.htm retrieved from internet September 2, 2009

Nafziger AN, Bertino, JS. Utility and application of urine drug testing in chronic pain management with opioids. Clin J Pain 2009; 25(1) 73-79.

National Government Services, Inc. LCD ((L28145) for Qualitative Drug Screening retrieved from http://www.cms.hhs.gov/mcd/search.asp?from2=search.asp& August 25, 2009.

Nicholson B, Passik, S. Management of chronic noncancer pain in the primary care setting. Southern Medical Journal 2007; 100(10)1028-1034.

Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo clinic proceedings. July 2009;84(7):593-601.

Schneider, J., Miller, A Urine drug tests in a private chronic pain practice (2008) Practical Pain management. January/February 2008. retrieved from http://www.tufts.edu/data/41/528854.pdf on Sept. 1, 2009.

Trescot AM, Standiford H, et al. Opioids in the management of chronic non-cancer pain: an update of American society of the interventional pain physicians’(ASIPP) guidelines. Pain Physician 2008; 11:S5-S62 issn 1533-3159

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Florida Contractor Advisory Committee Meeting held on October 16, 2010.

Puerto Rico and U.S. Virgin Islands Contractor Advisory Committee Meeting held on October 21, 2010.

Start Date of Comment Period 09/30/2010

End Date of Comment Period 11/13/2010

Start Date of Notice Period 12/30/2010

Revision History Number 6

Revision History Explanation Revision Number:6 Start Date of Comment Period:09/30/2010

Start Date of Notice Period:12/30/2010 Revised Effective Date: 02/13/2011

LCR B2010-085

December 2010 Update

Explanation of Revision: Under the “Indications” section of the LCD, language was added to clarify medically reasonable and necessary criteria. Under the “Limitations” section of the LCD, language was added to clarify point of service qualitative urine drug screen for number of units billed. In addition, under the “ICD-9 Codes that Support Medical Necessity” section of the LCD, diagnosis code 518.81 was added. Also, CPT 80100 was removed from the Indications and Limitations, CPT/HCPCS section of the LCD, based on CR7300, effective January 1,

2011. The effective date of this LCD revision is based on date of service. A note was added under the “CPT/HCPCS Codes” section of the LCD advising the new revised descriptor for HCPCS code G0431 is effective 01/01/2011 based on 2011 HCPCS Update. The effective date of this revision is for services rendered on or after 01/01/2011.

Revision Number:5

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2011 Revised Effective Date: 01/01/2011

LCR B2011-020

December 2010 Update

Explanation of Revision: Annual 2011 HCPCS Update. Descriptor revised for HCPCS code G0431. HCPCS code G0430 was deleted and replaced with HCPCS code G0434. The effective date of this revision is based on date of service.

Revision Number:4

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2010 Revised Effective Date:10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted ICD-9-CM code 970.8 and replaced with new ICD-9-CM code range 970.81-970.89. The effective date of this revision is based on date of service.

Revision Number 3

Start Date of Comment Period:N/A Start Date of Notice Period:08/01/2010 Revised Effective Date 07/06/2010

LCR B2010-056

July 2010 Update

Explanation of revision: Per CMS Change Request 6974, transmittal 1992, dated 06/25/2010, CPT procedure 80101 received an “I” status effective 1/1/2010. Because of this “I” status, CPT code 80101 has been removed from the “Indications and Limitations of Coverage and/or Medical Necessity” and from the “CPT/HCPCS Codes” sections of the LCD. Revisions are effective for claims processed on or after 7/6/2010 for dates of service on or after 1/1/2010.

Revision Number 2

Start Date of Comment Period:N/A Start Date of Notice Period:07/01/2010 Revised Effective Date 06/01/2010

LCR B2010-051

June 2010 Update

Explanation of revision: Explanation of revision: Under the “Indications” section of the LCD, deleted the statement “For management of chronic pain patients when there is a high pre-test suspicion of non-adherence to the prescribed drug regimen as documented in the patient’s medical record”. Added the statements “The management of patients with chronic pain in which there is a significant pre-test probability of non-adherence to the prescribed drug regimen as documented in the patient’s medical record” and “The management of patients with chronic pain in a designated pain management clinic where this select population has a significant pretest probability of drug interactions and side effects”. This revision is effective for claims processed on or after 06/01/2010, for dates of service on or after 01/25/2010.

Revision Number1

Start Date of Comment Period:N/A Start Date of Notice Period:05/01/2010 Revised Effective Date 04/01/2010

LCR B2010-037

April 2010 Update

Explanation of revision: Addition of CPT code 80100 and 80101 to the “Indications” and “CPT/HCPCS Codes” sections of the LCD. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:09/24/2009 Start Date of Notice Period:12/11/2009 Original Effective Date: 01/25/2010

LCR B2009-114

December 2009 Update

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

80100 descriptor was changed in Group 1 G0431 descriptor was changed in Group 1

11/21/2010 - The following CPT/HCPCS codes were deleted: G0430 was deleted from Group 1

01/23/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

G0431 descriptor was changed in Group 1 G0434 descriptor was changed in Group 1

04/09/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

G0431 descriptor was changed in Group 1

11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

G0434 descriptor was changed in Group 1

Reason for Change