This bulletin article applies to NC Medicaid Direct.
Effective Dec. 1, 2024, the allowable places of service are being revised for the following HCPCS codes:
| CPT Code | Description |
|---|---|
G0480 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed |
G0481 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed |
G0482 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed |
G0483 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed |
As a reminder, clinical coverage policy 1S-8, Drug Testing for Opioid Treatment and Controlled Substance Monitoring, requires documentation in the beneficiary’s health record of appropriate testing frequency based on the current treatment stage (for substance use treatment) or risk level (for chronic pain management), rationale for each drug class(es) ordered, results from previous laboratory tests (both presumptive and definitive), and how these results will inform care decisions.
Each test must be tailored to the individual; therefore, uniform lab orders across all beneficiaries in a practice (blanket order) and requisitions/orders requesting definitive testing for all drug classes are not compliant with coverage criteria and are prohibited. Definitive (quantitative) urine drug testing is covered only when the following criteria are met:
- For a specific substance or substances that produce an inconsistent result on presumptive screening;
- When the definitive test is individualized to a specific beneficiary based on history of use and substance(s) likely to be present (direct to definitive testing); or
- If the beneficiary presents with suspected substance use toxicity as described in subsection 3.2.1.1 of clinical coverage policy 1S-8.
Effective Dec. 1, 2024, HCPCS Codes G0481, G0482, and G0483 will be covered exclusively in emergency departments or inpatient care settings. This revision is based on the likelihood that a beneficiary would not have more than 7 drugs classes showing inconsistent results on a presumptive screening or be treated for the conditions specified in Subsection 3.2.1.1 of clinical coverage policy 1S-8 in an office setting. HCPCS Code G0480 will continue to be covered in the outpatient setting.
Refer to clinical coverage policy 1S-8 Drug Testing for Opioid Treatment and Controlled Substance Monitoring for specific criteria on when definitive drug testing is covered.
For beneficiaries enrolled in a managed care plan (PHP), providers should contact the appropriate health plan for that beneficiary. Contact information is available on the Health Plan Contacts and Resources webpage.
Contact
NCTracks Call Center: 800-688-6696