Draft Article - Billing and Coding: Urine Drug Testing (DA56818)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 - A/B MAC (B) Contacts with Independent Clinical LaboratoriesArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L36029 Urine Drug Testing.A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood, urine, or oral fluid sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.Common methods of drug analysis include chromatography, immunoassay, chemical ("spot") tests, and spectrometry.Coding GuidelinesOne presumptive drug testing code may be billed once per patient per day as indicated by the code description and should only be billed at one unit regardless of the provider.One definitive drug testing code may be billed once per patient per day as indicated by the code description and should only be billed at one unit regardless of the provider.The documentation should support the medical necessity of the drug testing ordered and should support the clinical indicators that led to ordering the test.Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the identity of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the service performed.Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering physician/treating physician must indicate the medical necessity for performing a drug test. All tests must be ordered in writing by the treating provider and all drugs/drug classes to be tested must be indicated in the order.If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the lab results, along with copies of the ordering/referring physicians order for the drug test. The physician must include the clinical indication/medical necessity in the order for the drug test.This LCD does not apply to acute inpatient claims.Claims for drug screening services are payable under Medicare Part B in the following places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center (freestanding) (50), rural health clinic (freestanding) (72), and independent laboratory (81).All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.All coverage criteria must be met before Medicare can reimburse this service.Billing for these services in a non-covered situation (e.g., does not meet indications of the LCD) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item, or procedure may not be covered by Medicare.The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category, or is rendered for screening purposes.