BCBS – Drug Testing in Pain Management and Substance Use Disorder Treatment – Medical Policy

Revision update 05-21-2021

Description section updated In Policy section:

• In items A, B, C, and D removed the word “urine” to read respectively: “A. In outpatient pain management, presumptive (i.e., immunoassay) drug testing…” “B. In outpatient substance use disorder treatment, in-office or point-of-care presumptive (i.e., immunoassay) drug testing…” “C. Definitive (i.e., confirmatory) drug testing…” “D. In outpatient pain management and outpatient substance use disorder treatment, drug testing is considered not medically necessary when the above criteria are not met including but not limited to routine presumptive or definitive drug testing…”
• In items A and B added “d. Drug testing is ordered by a clinician during an office visit”
• Replaced Items 3 and 4 “3. Stabilization phase – targeted weekly presumptive screening for a maximum of 4 weeks (see Policy Guidelines section) 4. Maintenance phase – targeted presumptive screening once every 1 to 3 months (see Policy Guidelines section)” with 2a and 2b “2. Stabilization and Maintenance phase a. Using an appropriate test, matrix and frequency of testing for the risk level of the individual and the substance being used (see Policy Guidelines section: Presumptive Testing – Selecting an appropriate test; Selecting an appropriate matrix; and Selecting an appropriate frequency of testing) b. Documentation in the medical record explains the following (see Policy Guidelines section): 1) Rationale for the specific test(s) ordered, 2) Patient’s history of substance use, 3) How drug testing results will guide medical decision-making”
• In Item D added “or standing orders (i.e., ” “definitive” and “and validity testing when used as a separate evaluation (see Policy Guidelines).” and removed “quantitative” to read “D. In outpatient pain management and outpatient substance use disorder treatment, drug testing is considered not medically necessary when the above criteria are not met including but not limited to routine presumptive or definitive drug testing or standing orders (e.g., testing at every visit, without consideration for specific patient risk factors or without consideration for whether definitive testing is required for clinical decision making) and validity testing when used as a separate evaluation (see Policy Guidelines).”
• Added F. “Drug testing in the following settings may be considered medically necessary: 1. Emergency rooms 2. Ambulatory surgery 3. Inpatient Services 4. An abrupt change in mental status (to rule out substance intoxication or delirium) 5. Drug or alcohol exposure during pregnancy 6. To rule out a fetal withdrawal syndrome by testing the mother for drug use.”

Policy Guidelines updated In Coding section:

• Added HCPCS Code: G0659
• Added PLA Codes: 0011U, 0054U, 0079U, 0117U, and 0227U
• Added ICD-10 Codes: F11.13, F14.13, F14.93

Rationale section updated

References updated

Source: https://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies/policies/DrugTesting_PainManagement_SubstanceUseDisorderTreatment_2021-04-21.pdf