Controlled Substances and Drugs of Abuse Testing

This electronic Comparative Billing Report (eCBR) focuses on providers who have submitted claims for controlled substance and drugs of abuse presumptive drug testing services CPT codes 80305–80306, and definitive drug testing services HCPCS codes G0480–G0483.

eCBRs information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare coverage guidelines.

For your personalized eCBR results on the specified drug testing services please, log into our eServices portal. An eCBR will be available for providers who have at least 10 claims in history for this CPT or HCPCS code family during the time period selected.

Overview of Controlled Substance Drugs of Abuse Testing Services
There are two main types of tests used to detect controlled substances and drugs of abuse:

• Presumptive tests: CPT codes 80305–80306 are tests that detect the presence of any number of drug classes, utilizing any number of devices or procedures, per date of service. The methods used to read these tests are based on the CPT code definitions.
• Definitive tests: HCPCS codes G0480–G0483 are tests utilizing drug identification methods that identify individual drugs and differentiate between all structural isomers, qualitative or quantitative, including specimen validity testing, per date of service. The methods used to read these tests, are based on the difference in the HCPCS codes and the number of drug classes tested, not the cumulative number of drugs/metabolites tested.

Summary of HCPCS Codes for Drugs of Abuse Testing

It is important to note that a definitive drug test may be performed when a presumptive test is negative for a patient on a prescribed medication.

Only one presumptive service may be billed per patient, per date of service, regardless of the provider. Medicare will process the first presumptive service received per patient, per date of service. All subsequent claims for a presumptive service for the same patient and same date of service will be denied.

Only one definitive service may be billed per patient, per date of service, regardless of the provider. Medicare will process the first definitive service received per patient, per date of service. All subsequent claims for a definitive service for the same patient and same date of service will be denied.

The date of service refers to the date of the sample collection, not the date the test was run. To receive reimbursement for controlled substance and drugs of abuse testing, the service reported on the claim must match the service ordered by the physician.

Methods:
The metrics reviewed in this eCBR are the proportion of billing for each drug testing services HCPCS or CPT code with comparisons to peers within the nationwide Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) Jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your claims for CPT codes 80305–80307 and HCPCS codes G0480–G0483 at levels compared to your peers in the RRB SMAC.

Example of eCBR Results from eServices:

Please be aware that the information contained within this eCBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.

For more information about this or other eCBRs, please call our Provider Contact Center at 888-355-9165, and select Option 5. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. to 4:30 p.m. in all time zones with the exception of Pacific Time. This service is available from 8:30 a.m. to 4 p.m. PT.

Educational Resources:
CMS Resources

• CMS Clinical Labs Center
• IOM Pub.100-04, Medicare Claims Processing Manual, Chapter 16 – Laboratory Services (PDF, 560 KB)
• IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.1 – Clinical Laboratory Services (PDF, 1.33 MB)
• CMS National Coverage Determinations for Laboratory Services 
• CMS MLN Fact Sheet Complying with Documentation Requirements for Laboratory Services (PDF, 870 KB)
• MLN Matters SE18001 (PDF, 205 KB) Proper Coding for Specimen Validity Testing Billed in Combination with Drug Testing 

Palmetto GBA Railroad Medicare Resources

• Orders for Diagnostic Tests
• Drug Screening Checklist (PDF, 60 KB)
• Laboratory Services: Submitting Requested Documentation to the CERT