Local Coverage Determination for Qualitative Drug ...

1 Local Coverage Determination (LCD) for Qualitative DrugScreening (L30574)Contractor InformationContractor NameFirst Coast Service Options, Number09102 Contractor TypeMAC - Part BBack to TopLCD InformationDocument InformationLCD ID NumberL30574 LCD TitleQualitative drug ScreeningContractor's Determination NumberG0431 AMA CPT/ADA CDT Copyright StatementCPT codes, descriptions and other data onlyare copyright 2011 American MedicalAssociation (or such other date of publicationof CPT). All Rights Reserved. ApplicableFARS/DFARS Clauses Apply.

2 Current DentalTerminology, (CDT) (including procedurecodes, nomenclature, descriptors and otherdata contained therein) is copyright by theAmerican Dental Association. 2002, 2004 American Dental Association. All rightsreserved. Applicable FARS/DFARS Geographic JurisdictionFloridaOversight RegionRegion IVOriginal Determination Effective DateFor services performed on or after 01/25/2010 Original Determination Ending DateRevision Effective DateFor services performed on or after 02/13/2011 Revision Ending DateCMS national Coverage PolicyLanguage quoted from CMS national Coverage Determination (NCDs) and coverageprovisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD).

3 NCDs and Coverage provisions in interpretive manuals are not subject to the LCDR eview Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, anadministrative law judge may not review an NCD. See 1869(f) (1) (A)(i) of the SocialSecurity otherwise specified, italicized text represent quotation from one or more of thefollowing CMS sources:Printed on 2/3/2012. Page 1 of 10 CMS Manual System, Pub. 100-03, Medicare national Coverage Determinations Manual,Chapter 1 Request 6852, transmittal 653, dated March 19, 2010 Change Request 6974, transmittal 1992, dated June 25, 2010 Indications and Limitations of Coverage and/or Medical NecessityA Qualitative drug screen reports the presence of a drug in a blood or urine specimen.

4 Ablood or urine sample may be used. Urine is usually the preferred specimen type due to itssensitivity to many common drugs compared to blood specimens. A Qualitative drug screenmay be indicated when the history is unreliable, with a multiple- drug ingestion, with a patientin delirium or coma, for the identification of specific drugs, and to indicate when antagonistsmay be will consider performance of a Qualitative drug screen (HCPCS codesG0431/G0434) medically reasonable and necessary for the following:When the patient presents with suspected drug overdose or suspected drug misuse and oneor more of the following indications.

5 Unreliable patient history Multiple drug ingestions Unexplained delirium or coma Unexplained altered mental status in the absence of a clinically defined toxic syndromeor toxidrome Severe or unexplained cardiovascular instability (cardiotoxicity) Unexplained metabolic or respiratory acidosis Suspected history of substance abuse Seizures with an undetermined historyOR for one of the following indications: The management of a patient under treatment for substance abuse when there issuspicion of continued substance abuse The management of a patient with chronic pain in which there is a significant pre-testprobability of non-adherence to the prescribed drug regimen as documented in thepatient s medical record The management of patients with chronic pain in a designated pain management clinicwhere this select population has a significant pretest probability of drug interactions andside effectsLimitationsPrinted on

6 2/3/2012. Page 2 of 10 Medicare will consider the performance of a Qualitative drug screen not medically reasonableand necessary for the following: Simultaneous blood and urine specimen screening Medicolegal purposes ( , court-ordered drug screening, forensic examinations) Employment or recreational purposes Routine screening performed as part of a physician s protocol for treatment in absence ofany of the above indicationsRoutine urinalysis/urine creatinine performed on the same date of service/claim for thepurpose of validating the urine specimen is considered screening.

7 There is no screeningbenefit for routine urinalysis or urine creatinine, therefore, both will be denied whenperformed on the same date of service as the Qualitative drug management of patients under treatment of substance abuse or management of patientswith chronic pain, point of service Qualitative urine drug screen is the most frequently utilizedtesting. This testing is described by G0434 and is billed one unit per patient to TopCoding InformationBill Type Codes:Contractors may specify Bill Types to help providers identify those Bill Types typically used toreport this service.

8 Absence of a Bill Type does not guarantee that the policy does not applyto that Bill Type. Complete absence of all Bill Types indicates that Coverage is not influencedby Bill Type and the policy should be assumed to apply equally to all ApplicableRevenue Codes:Contractors may specify Revenue Codes to help providers identify those Revenue Codestypically used to report this service. In most instances Revenue Codes are purely advisory;unless specified in the policy services reported under other Revenue Codes are equallysubject to this Coverage Determination .

9 Complete absence of all Revenue Codes indicatesthat Coverage is not influenced by Revenue Code and the policy should be assumed to applyequally to all Revenue ApplicableCPT/HCPCS CodesGroupNamePrinted on 2/3/2012. Page 3 of 10 NOTE: Effective January 1, 2011, based on the 2011 HCPCS Update, the descriptor forHCPCS code G0431 was revised to read: drug screen, Qualitative ; multiple drugclasses by high complexity test method ( , immunoassay, enzyme assay), perpatient encounter. 80102 drug CONFIRMATION, EACH PROCEDUREG0431 drug SCREEN, Qualitative ; MULTIPLE drug CLASSES BY HIGHCOMPLEXITY TEST METHOD ( , IMMUNOASSAY, ENZYMEASSAY), PER PATIENT ENCOUNTERG0434 drug SCREEN, OTHER THAN CHROMATOGRAPHIC.

10 ANY NUMBEROF drug CLASSES, BY CLIA WAIVED TEST OR MODERATECOMPLEXITY TEST, PER PATIENT ENCOUNTERICD-9 Codes that Support Medical drug DEPENDENCE UNSPECIFIED CONVULSIVE EPILEPSY WITHOUT CONVULSIVE EPILEPSY WITH MAL STATUS UNSPECIFIED WITHOUT INTRACTABLE UNSPECIFIED WITH INTRACTABLE BLOCK DEGREE ATRIOVENTRICULAR (TYPE) II ATRIOVENTRICULAR SECOND DEGREE ATRIOVENTRICULAR QT SUPRAVENTRICULAR VENTRICULAR RESPIRATORY OF CONSCIOUSNESS BY ANTIALLERGIC AND ANTIEMETIC BY OPIUM (ALKALOIDS) BY BY BY OTHER OPIATES AND RELATED BY BY AROMATIC ANALGESICS NOT ELSEWHERECLASSIFIEDP rinted on 2/3/2012.