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Urine drug screening reminders for Medicaid Behavioral Health codes

2/15/2019 9:24:11 AM

Drug Testing (urine/serum) Frequency Guidelines per Indication for testing – must be supported by documentation in the medical record and will require prior authorization if the testing exceeds the following limits:

Diagnosis of altered mental status:

  • At the time of the initial medical evaluation.
  • Subsequent testing in a treatment center (clinic or office) must be medically necessary and not performed for the sole purpose of validating observable signs of intoxication.
  • In patients with unexplained alteration of mental status and when knowledge of drug use is necessary for medical management (e.g., emergency department evaluation for altered mental status), UDT (presumptive and confirmatory definitive testing, if indicated) is covered in addition to these limitations.

Diagnosis of a medical condition where drug toxicity may be a contributing factor:

  • At the time of the initial medical evaluation.

Behavioral Health Treatment Programs:

  • Assessment of patients for a behavioral health treatment program to determine the patient’s substance profile and detoxification regime.
  • Further testing during treatment must be supported by documentation in the medical record and will not exceed 36 presumptive and 12 definitive units per year without a prior authorization.
  • Definitive testing is limited to no more than seven substances per day.

 

Pain Management Program (Non-Behavioral Health):

 

Presumptive/Screening Urine Drug testing is medically necessary for the following:

  • Baseline screening before initial entrance into a pain management program

  • For patients receiving chronic opioid therapy for chronic pain, frequency of testing depending on the *patient’s risk level (using a validated opioid risk assessment tool).

  • Presumptive screening for compliance monitoring may be appropriate for up to 12 times per year with provision for monitoring for unexpected results, complaints or *aberrant behavior

  • Definitive testing should be conducted only for confirmatory purposes and should not exceed 12 units per year.Definitive testing is limited to no more than seven substances per day.

  • All testing during treatment must be supported by documentation in the medical record and will not exceed 12 units per year without a prior authorization.

*Aberrant behavior includes, but is not limited to, lost prescriptions, repeat requests for early refills, prescriptions from multiple providers, unauthorized dose escalation, and apparent intoxication.

 

These are the associated codes:                             

                                 

            G0477 - CMS has cross walked this code to CPT code 80305 (presumptive).                  

                                  

            G0478 - CMS has cross walked this code to CPT code 80306 (presumptive)                   

                                   

            G0479 - CMS has cross walked this code to CPT code 80307 (presumptive)                    

                                   

            G0480 Drug test(s), definitive           

                                   

            G0481 Drug test(s), definitive           

                                   

            G0482 Drug test(s), definitive           

                                   

            G0483 Drug test(s), definitive           

 


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