This bulletin article applies to NC Medicaid Direct and NC Medicaid Managed Care.
A bulletin, Terminating Coverage of Some Definitive Drug Testing Codes, was published on Oct. 11, 2024, informing providers that places of service would be restricted to the emergency and inpatient places of service effective Dec. 1, 2024, for the following HCPCS codes:
CPT Code | Description |
|---|---|
| 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 |
Based on the feedback received, NC Medicaid has decided to restore coverage of these services to the outpatient setting, including CLIA-certified offices and laboratories. This change will be retroactive to Dec. 1, 2024. Providers can resubmit NC Medicaid Direct claims that were denied due to place of service retroactive to dates of service on or after Dec. 1, 2024. NC Medicaid Managed care health plans have been notified of this change and are in the process of updating their systems. All managed care health plans are required to have system changes in place by April 21, 2025, and claim resubmissions adjudicated or reprocessed no later than May 21, 2025.
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
NCTracks Call Center: 800-688-6696
NC Managed Care health plans