L30574

 

QUALITATIVE DRUG SCREENING

 

02/13/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

 

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:

o Unreliable patient history

o Multiple drug ingestions

o Unexplained delirium or coma

o Unexplained altered mental status in the absence of a clinically defined toxic syndrome or toxidrome.

o Severe or unexplained cardiovascular instability (cardiotoxicity)

o Unexplained metabolic or respiratory acidosis

o Suspected history of substance abuse

o Seizures with an undetermined history

• OR for one of the following indications:

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

o 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

o 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:

o Simultaneous blood and urine specimen screening

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

o Employment or recreational purposes

o 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.

o 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.

o This testing is described by G0434 and is billed one unit per patient encounter.

 

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

427.0 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

427.1 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

965.00 POISONING BY OPIUM (ALKALOIDS) UNSPECIFIED

965.01 POISONING BY HEROIN

965.02 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

967.0 POISONING BY BARBITURATES

967.1 POISONING BY CHLORAL HYDRATE GROUP

967.2 POISONING BY PARALDEHYDE

967.3 POISONING BY BROMINE COMPOUNDS

967.4 POISONING BY METHAQUALONE COMPOUNDS

967.5 POISONING BY GLUTETHIMIDE GROUP

967.6 POISONING BY MIXED SEDATIVES NOT ELSEWHERE CLASSIFIED

967.8 POISONING BY OTHER SEDATIVES AND HYPNOTICS

967.9 POISONING BY UNSPECIFIED SEDATIVE OR HYPNOTIC

969.00 POISONING BY ANTIDEPRESSANT, UNSPECIFIED

969.01 POISONING BY MONOAMINE OXIDASE INHIBITORS

969.02 POISONING BY SELECTIVE SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS

969.03 POISONING BY SELECTIVE SEROTONIN REUPTAKE INHIBITORS

969.04 POISONING BY TETRACYCLIC ANTIDEPRESSANTS

969.05 POISONING BY TRICYCLIC ANTIDEPRESSANTS

969.09 POISONING BY OTHER ANTIDEPRESSANTS

969.1 POISONING BY PHENOTHIAZINE-BASED TRANQUILIZERS

969.2 POISONING BY BUTYROPHENONE-BASED TRANQUILIZERS

969.3 POISONING BY OTHER ANTIPSYCHOTICS NEUROLEPTICS AND MAJOR TRANQUILIZERS

969.4 POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS

969.5 POISONING BY OTHER TRANQUILIZERS

969.6 POISONING BY PSYCHODYSLEPTICS (HALLUCINOGENS)

969.70 POISONING BY PSYCHOSTIMULANT, UNSPECIFIED

969.71 POISONING BY CAFFEINE

969.72 POISONING BY AMPHETAMINES

969.73 POISONING BY METHYLPHENIDATE

969.79 POISONING BY OTHER PSYCHOSTIMULANTS

969.8 POISONING BY OTHER SPECIFIED PSYCHOTROPIC AGENTS

969.9 POISONING BY UNSPECIFIED PSYCHOTROPIC AGENT

970.81 POISONING BY COCAINE

970.89 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.

 

 

Documentation 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.

o 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.

o 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.

o 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.

o Additionally, a copy of the lab results should be maintained in the medical records.

Utilization Guidelines

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o 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.

o The reason for the qualitative drug screening must be documented in the evaluation and

o Management of the patient.

Treatment Logic

• 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.

 

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 issue 1533-3159

 

02/13/2011

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L30574 QUALITATIVE DRUG SCREENING