Quantitative and Qualitative Drug Screens for Illicit Use of

Transcription

Clinical Policy Title: Drug Screens — Quantitative and Qualitative Drug Screens for
Illicit Use of Pharmaceuticals
Clinical Policy Number: 00.01.02
Effective Date:
Initial Review Date:
Most Recent Review Date:
Next Review Date:
Oct. 1, 2014
May 21, 2014
June 18, 2014
May, 2015
Policy contains:
• Qualitative drug screening method for
illicit drug use.
• Quantitative drug screening method for
illicit drug use.
Related Policies: (391) 00.01.01, Drug Testing in Addiction Treatment and Monitoring.
ABOUT THIS POLICY: Select Health of South Carolina has developed clinical policies to assist with making coverage determinations. Select Health
of South Carolina clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services
(CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional
literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including
any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by Select Health of
South Carolina when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal
laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Select Health of
South Carolina clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other
health care providers are solely responsible for the treatment decisions for their patients. Select Health of South Carolina clinical policies are
reflective of evidence-based medicine at the time of review. As medical science evolves, Select Health of South Carolina will update its clinical policies
as necessary. Select Health of South Carolina clinical policies are not guarantees of payment.
Coverage policy
I. Qualitative screening:
Select Health of South Carolina considers the use of qualitative drug screening to be clinically
proven and therefore, medically necessary when the following criteria are met:
A. Verification of abstinence for use of drugs through episodic monitoring as part of a behavioral
health or substance abuse treatment program. OR
B. Qualitative drug screen performed as part of the evaluation and treatment of a member who
presents in urgent/emergency room care settings with suspected drug overdose or suspected drug
misuse and ONE or MORE of the following indications:
1. Unexplained coma.
FC-12092014-P-002 | Clinical Guideline 00.01.02 Drug Screens - Quantitative and Qualitative Drug Screens for Illicit Use of Pharmaceuticals
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2.
3.
4.
5.
6.
7.
8.
Unexplained altered mental status in the absence of a clinically defined toxic syndrome
or toxidrome.
Severe or unexplained cardiovascular instability (cardiotoxicity).
Unexplained metabolic or respiratory acidosis in the absence of a clinically defined
toxic syndrome or toxidrome.
Seizures with an undetermined history.
Multiple drug ingestions.
To provide antagonist to specific drug.
Member presents with clinical signs/symptoms and/ or history of substance abuse.
9. High-risk pregnancy only when the documented member history demonstrates the
procedure is medically necessary.
10. EPSDT services only when the documented member history demonstrates the
procedure is medically necessary.
11. The management of a member under treatment for substance abuse when there is
suspicion of continued substance abuse.
12. The management of a member with chronic pain in which there is a significant pretest
probability of nonadherence to the prescribed drug regimen as documented in the
member’s medical record.
13. The management of members with chronic pain in a designated pain management
clinic where this select population has a significant pretest probability of drug
interactions and side effects.
Figure 1.
Drugs or classes of drugs commonly assayed by a qualitative screen followed by confirmation
with a second method include the following:
1. Alcohols/ethanol — not part of a qualitative urine drug screen; alcohol testing is not
performed by immunoassay.
2. Amphetamines/methamphetamine.
3. Barbiturates.
4. Benzodiazepines.
5. Cocaine and metabolites.
6. Methadones.
7. Methaqualones.
8. Opiates.
9. Phencyclidines.
10. Phenothiazines.
11. Propoxyphene.
12. Tetrahydrocannabinoids.
13. Tricyclic antidepressants.
(See Figure 2 for parameters)
II. Quantitative screening/confirmation screening
Select Health of South Carolina considers the use of quantitative drug screening to be clinically
proven and therefore, medically necessary when the following criteria are met:
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1. Drugs or drug classes for which testing is performed should reflect only those likely to
be present and for which knowledge of the absolute level will impact clinical decisionmaking. OR
2. Quantified and confirmation drug screen is indicated when the result of the drug screen
is different than that suggested by the patient’s medical history, clinical presentation or
patient’s own statement. AND
3. Quantitative testing exceeding three procedure codes or drug classes every 30 days
requires rationale documented in the medical record and must meet medical necessity.
Routine testing at the upper end of these limits may result in audit and/or overpayment
demands among other available regulatory action. AND
4. All orders for confirmation testing (qualitative result, CPT 80102) require a positive
screening test and shall be performed only for the drug class represented by the
positive screening. (See CMS Local Coverage Determinations: L30574, L28145 and
L32050.) AND
5. Technically quantitative or confirmatory tests must have high specificity.
Figure 2.
Parameters for quantification or confirmation testing of drug screens
A. Quantitation testing requires a positive qualitative screening test and shall be performed only for the
drug class represented by the positive qualitative screening. Automatic confirmatory testing for any
drug is not reasonable and necessary without patient specific indications. Select Health of South
Carolina considers confirmatory/quantitative drug testing reasonable and necessary when the results
of a qualitative screen are:
1. Cocaine confirmation to identify a chronic cocaine user.
2. THC (tetrahydrocannabinoids) confirmation to document patient’s discontinuation of THC
use according to the treatment plan.
3. Negative screen inconsistent with patient’s medical history or currently prescribed pain
medications.
4. Suspicion of a specific drug use, such as but not limited to Fentanyl and Meperidine, or
“designer drugs.”
B. National pain organizations and the Federation of State Medical Boards do not advocate routine and
comprehensive drugs-of-abuse testing. Frequency of testing beyond the baseline drug screen must be
based on individual patient needs substantiated by documentation in the medical record.
Limitations — Select Health of South Carolina does not provide coverage for testing that is not medically
necessary. This includes but is not limited to:
• Quantitative drug testing is allowed for a single drug on the day of service. Quantitative drug
testing for multiple drugs requires a statement of medical necessity.
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•
•
•
•
•
•
•
Same-day screening of drug metabolites in both a blood and a urine specimen by either
qualitative or quantitative analyses.
For medico-legal purposes (i.e., court-ordered drug screening, forensic examinations).
For employment purposes (i.e., as a prerequisite for employment or as a means for
continuation of employment).
As a component of routine physical/medical examination.
As a component of medical examination for administrative purposes.
As a routine component of a behavioral health assessment.
Any of the following is sufficient criteria for exclusion:
o Confirmation or quantitative testing is excluded from coverage if performed for
forensic or legal purposes.
o Quantitative testing requires a positive screening test and shall be performed only for
the drug class represented by the positive screening.
o Unvalidated source of the tested specimen.
All other uses of qualitative drug screening are not medically necessary.
NOTE for Select Health the following codes are covered by facility only:
• 80100 - Drug screen, qualitative; multiple drug classes chromatographic method, each procedure;
• 80102 - Drug confirmation, each procedure;
• 80104 - Drug Screen, qualitative; multiple drug classes other than chromatographic method, each
procedure.
• The following code is not listed on the South Carolina Medicaid Fee Schedule:
o G0434 - Drug screen, other than chromatographic; any number of drug classes, by CLIA
waived test or moderate complexity test, per patient encounter.
Alternative covered services — Physician office visits and routine lab screenings.
Background
The collection and analysis of body fluids, especially urine samples, for the detection of alcohol, nicotine,
others drugs or their metabolites, is a common feature of many addiction treatment services. The chemical
compounds that act on reward pathways in the brain can be taken into the body by various routes.
Laboratory testing for drugs of abuse is a medically necessary and useful component of chemical
dependency treatment. The drug screen result influences treatment and level of care decisions. Ordered
tests must match treatment needs, the documented history and Diagnostic and Statistical Manual of
Mental Disorders (DSM IV TR) or most current DSM diagnosis.
Provider should test for a broad range of commonly abused drugs to screen a patient for substance use
disorders. Decisions about screened substances must be documented and based on the following criteria:
a. Patient history, physical examination, and previous laboratory findings.
b. Suspected abused substance.
c. Substances that may present high risk for additive or synergistic interactions with prescribed
medication (e.g., benzodiazepines or alcohol).
Quantitative drug testing is generally used when it is medically necessary to determine the specific quantity
of drug or drug metabolite present in the sample. The test result is expressed in numerical terms.
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The traditional clinical role of urine drug testing (UDT) has been to support treatment decisions made in the
urgent care setting where patients are unable or, in some cases, unwilling to provide information about the
use of substances that may be harmful to them. When used effectively, however, UDT is more than just a
verification tool and has many useful clinical applications in patient-centered testing. No “standard” UDT is
suitable for all purposes and settings — rather, a multitude of options exists, that health care professionals
should adapt to their particular clinical needs.
The two main types of UDT — which are often used in combination — are:
1. Immunoassay drug testing, either laboratory-based or at point-of-care (POC).
2. Laboratory-based specific drug identification†: e.g., gas chromatography/mass spectrometry‡
(GC/MS) or liquid chromatography/mass spectrometry§ (LC/MS).
UDT typically detects the parent drug and/or its metabolite(s) and, therefore, demonstrates recent use of
prescription medications, unprescribed drugs and illegal substances. Although other biologic specimens can
be used in drug testing, urine is usually preferred for determining the presence or absence of drugs because
it has a one- to three-day window of detection for most drugs and/or their metabolites and is currently the
most extensively validated biologic specimen for drug testing.
In settings in which drug testing is done routinely for many people, the American Society of Addiction
Medicine (ASAM) encourages using the full range of biological matrices — both POC and laboratory-based
tests. In settings where testing is now seldom or never done, ASAM encourages using drug tests that are
easily adopted, such as urine or oral fluid testing. When testing is done in high-risk populations, such as in
addiction treatment, the criminal justice system, and return-to-work settings after addiction treatment,
ASAM encourages the use of random rather than scheduled drug tests. The frequency of the random tests
can be varied to fit the needs of the tested population just as frequency of testing in clinical settings
changes with clinical indications. For example, more frequent testing at the outset may be used until stable
abstinence is achieved, followed by less frequent testing as abstinence is maintained. This approach to
random testing increases the effectiveness of the testing in promoting recovery and is far less expensive.
Moreover, testing is most intense for the subjects at highest risk of drug use.
In scheduled tests, consideration should be given to matrices more resistant to subversion, especially hair
and oral fluid. Random, directly-observed testing with the donor accompanied to the restroom directly
after notification of the test is the most effective way to reduce subversion with urine tests, but balancing
this with privacy concerns and other practicalities should be case- and/or context-specific. When
subversion of a urine drug test is proven or suspected, it is incumbent to perform an immediate recollection
under monitored conditions. In many clinical settings oral fluid would be a common secondary matrix to
test. Though not offered by as many laboratories, a hair test could be used as it is more resistant to
subversion and offers an extended detection window. However, a hair test will not detect very recent use,
and to detect marijuana, this approach must be frequent and sustained.
Drug tests are valuable tools for health care professionals to use as part of a comprehensive evaluation of
patients in order to reach the correct diagnosis and develop appropriate therapeutic interventions and
monitoring plans. They are tools that can improve diagnosis and treatment, just as laboratory testing is a
central component of most areas of health care to improve clinical accuracy and outcomes. Increasing the
use of drug testing in both medical and nonmedical settings has the potential to improve public health by
discouraging unhealthy or illicit drug use, and by promoting early identification of substance use disorders.
Drug testing should be a key component of assessment and treatment planning, especially when integrated
with other clinical information gathering, such as a substance use history, physical and mental status
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examinations, withdrawal severity scores, and standardized laboratory assessments of metabolic,
neurologic, and psychiatric status. A knowledgeable clinician can use drug testing to verify self-reports,
confirm diagnoses, identify denial and minimization of drug and alcohol use, enhance motivation for
treatment, measure biological adaptation, assist in development of treatment planning, monitor treatment
response, document treatment effectiveness and outcomes, support patient advocacy by validating
abstinence from alcohol and drug use, and validate adherence in taking prescribed controlled substances.
Methods
Searches:
Select Health of South Carolina searched PubMed and the databases of:
• UK National Health Services Centre for Reviews and Dissemination.
• Agency for Healthcare Research and Quality Guideline Clearinghouse and evidence-based practice centers.
• The Centers for Medicare & Medicaid Services.
Searches were conducted in April 2014 using the terms “qualitative,” “quantitative” and "drug testing.” Included were:
• Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision
of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods
to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidencegrading hierarchies.
• Guidelines based on systematic reviews.
• Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies),
reporting both costs and outcomes — sometimes referred to as efficiency studies — which also rank near the top
of evidence hierarchies.
Findings:
There is no scientific evidence to support the notion that quantitative UDT provides more information than
qualitative UDT with respect to determining patient adherence with specific dosing recommendations.
Negative urine for a prescribed drug should not be interpreted as definitive evidence of criminal behavior,
such as diversion. In addition, quantitative assessment of a drug analyte in urine does not provide reliable
evidence of diversion. Another limitation of UDT is that the presence of a prescribed drug cannot
distinguish whether the patient has been taking the drug as directed or using only a portion of the
prescribed medication (potentially hoarding or diverting the rest). While it is tempting to think that
quantitative UDT results might clarify these issues, at the present time neither blood nor urine drug
concentrations have been scientifically demonstrated to answer these questions. Therefore, it is important
that UDT is interpreted within the whole clinical context of the patient, including other methods of
assessing adherence (e.g., pill counts, PMPs).
In the absence of specific symptoms of medication aberrant behavior or misuse, qualitative drug testing is
reasonable and necessary when titrated to patient risk potential.
National pain organizations and the Federation of State Medical Boards recommend a practical approach to
confirmatory drug testing, and don’t advocate routine and comprehensive drugs of abuse testing.
Frequency of testing beyond the baseline drug screen must be based on individual patient needs
substantiated by quantification, and should not be used to determine adherence with a specific dosage or
formulation regimen.
Summary of Clinical Evidence
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Citation
Starrels, J.,
et.al. (2011)
Content, methods, recommendations
Key Point: Increase in drug testing in pain management. The use of
drug testing in pain management has increased exponentially over the
past decade. This fact conceals three
important realities:
1. Drug testing remains underutilized in pain management. A
recent survey of physician members of the American Pain
Society, the American Academy of Pain Medicine, and the
American Society of Regional Anesthesia and Pain Medicine
found that only 59% of respondents order random urine drug
testing.
2. Drug testing is highly skewed by medical specialty. Medicare
data shows that anesthesiologists (who comprise 74% of pain
specialists) ordered nearly as many drug tests in 2009
(636,880) as family practice physicians (258,132), internal
medicine physicians (241, 431), neurologists (128,713), and
general practitioners (70,031) combined. A recently published
study of a large primary care health system found that only 8%
of patients receiving long-term opioid therapy — and only 24%
of the highest risk patients — were evaluated via urine drug
testing.
Quest
Diagnostics
(2013),
Centers for
Disease
Control and
Prevention.
(2012)
3. Evidence indicates that, regardless of specialty, many
physicians who employ drug testing are not proficient in
interpreting test results.
Key Point: Prescription drug monitoring
• Data from Quest Diagnostics’ prescription drug monitoring service
indicates that 60% of drug test specimens from patients referred by
their physicians had results inconsistent with the controlled
substances prescribed.
• Only 40% of patients tested positive for prescribed medications
and negative for other drugs.
• Twenty-five percent of patients tested negative for all drugs,
including medications prescribed by their physicians, 15% were
negative for the prescribed drug and positive for another unprescribed drug, and 20% were positive for both the prescribed
medications and other drugs.
• Marijuana, present in 26% of specimens, was the most frequently
detected non-prescribed drug among patients with inconsistent
test results.
• Additionally, individuals in this study who tested positive for
marijuana were more likely to test positive for non-prescribed
pharmaceuticals (45%) than individuals who tested negative for
marijuana (36%).
• Following marijuana, the most common non-prescribed drug
classes identified in this study included opiates (22%),
benzodiazepines (16%), oxycodone (14%), cocaine (8%) and
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methadone (6%).
The study concluded that when drug testing is not employed,
physicians lack essential information about their patients’ patterns
of drug use, missing both the use of non-prescribed drugs and the
misuse and diversion of prescribed drugs.
•
Screening vs. Confirmatory Tests
There are two main categories of urine drug testing — screening and confirmatory. Screening tests are
initial, qualitative drug tests conducted to identify classes of drugs present in the urine and typically are
done using immunoassay. They rely on a set threshold above which a positive result is produced and
therefore do not detect lower concentrations of a drug. Confirmatory tests are used for further analysis of a
sample — to confirm a positive, or sometimes negative, result and typically are done using GC/MS or high
performance liquid chromatography (HPLC). Confirmatory testing can identify a specific drug. If the goal is
to detect a synthetic or semisynthetic opioid, this test should be used, as immunoassays do not typically
detect these opioids. Below is a comparison of the general characteristics of these two types of testing:
Screening (POC testing is usually only
screening)
Confirmatory
Analysis Technique
Immunoassay.
GC/MS or HPLC.
Sensitivity (power to
detect a class of drugs)
Low or none when testing for semi-synthetic
or synthetic opioids.
High.
Specificity (power to
detect an individual drug)
Varies based on assay used; can result in
false positives and false negatives.
High.
Use
Qualitative analysis; detects classes of drugs
(Heit and Gourley, 2004).
Quantitative analysis;
identifies a specific drug.
Cost
Inexpensive (FDA five-drug testing kit ~$1).
More expensive, may not be
paid for by insurance.
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Turnaround
On-site, rapid.
Slow.
Other
Intended for use in drug-free population;
may not be useful in pain medicine context.
Legally defensible results.
(Compton, 2007; Heit and Gourlay, 2004; Reisfeld, et al, 2007.)
Glossary
Baseline testing — Used to identify the presence of illicit substances prior to prescribing controlled
medications. To confirm the presence or absence of prescribed drug/drug class.
CLIA-waived drug screening test — Consists of cards, dipsticks, cassettes and cups based on qualitative
competitive immunoassay methodology with one or more analytes in the test.
Confirmation testing — Generally used to evaluate initial qualitative screening results to minimize the
potential of a clinician relying on a false negative or positive result. Confirmation testing is often
recommended when initial screening involves a CLIA-waived or moderate immunoassay screening, but is
not medically necessary in all patient cases. A confirmation test order must be medically necessary and
reasonable and patient self-report may, in some cases, reduce the need for confirmation of screen results.
Confirmation tests may be expressed in qualitative (CPT 80102) or quantitative (codes within the
Therapeutic or Chemistry sections of the CPT coding manual) values.
The use of qualitative versus quantitative confirmation testing depends upon the individual patient’s case
and medical necessity thereof.
COT — Chronic opioid therapy.
Point-of-care (POC) — POC devices typically use immunochromatographic methods that produce visually
read results.
Medicolegal — Pertaining to legal aspects of the practice of medicine, such as malpractice, patient consent
for operations or patient information.
Qualitative drug testing — Generally used to determine the presence or absence of drug or drug
metabolite in the sample. The test result is expressed in non-numerical terms, with a negative or positive
result.
Quantitative drug testing — Generally used when it is medically necessary to determine the specific
quantity of drug or drug metabolite present in the sample. The test result is expressed in numerical terms.
Quantification —The determination of drug concentration in the matrix with a specific numerical value. For
example, THC 50 ng/ml in urine is also referred to as quantitation.
Scheduled testing — Testing that is done at a routine time, as distinct from random testing.
Screening test — A drug test that is designed to be rather sensitive and affordable; the results have lower
specificity than a confirmatory test. This term, though imprecisely used, describes an initial immunoassay
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test to identify the presence of classes of prescribed and non-prescribed medications and drugs-of- abuse,
rather than devoting the more rigorous and expensive technologies of confirmatory testing.
Substance abuse — Abuse is synonymous with harmful use of a specific psychoactive substance. The term
“substance abuse” applies to one category of psychoactive substance-related disorders in previous editions
of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM)
but has been supplanted by the newer term, “substance use disorder.” While recognizing that the term
“abuse” is part of past diagnostic terminology, ASAM recommends that an alternative term be found for
this purpose because of the pejorative connotations of the word “abuse.”
Urine drug testing (UDT) — The collection and analysis of urine samples for the detection of alcohol,
nicotine or other drugs or their metabolites.
References
Professional Society Guidelines:
American Society of Addiction Medicine, Comprehensive MRO (Medical Review
Officer): http://www.asam.org/education/comprehensive-mro-(medical-review-officer) Accessed April 29,
2014.
John Hopkins University School of Medicine, Urine Drug Testing in Clinical Practice: The Art and Science of
Patient Care General Counsel, Johns Hopkins Medicine (4/1/03), Updated 4/09.
Centers for Disease Control and Prevention. (2012). CDC grand rounds: prescription drug overdoses – a U.S.
epidemic. Morbidity and Mortality Weekly Report, 61(1), 10-13.
Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm. Accessed May 12, 2014.
Center for Substance Abuse Treatment. (2012).Clinical drug testing in primary care. Technical Assistance
Publication (TAP) Series, 32. DHHS Publication No. (SMA) 12-4668. Rockville, MD: Substance Abuse and
Mental Health Services Administration.
Available: http://www.kap.samhsa.gov/products/manuals/pdfs/TAP32.pdf. Accessed May 12, 2014.
American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women.
(2011). Committee Opinion No. 479: Methamphetamine abuse in women of reproductive age. Obstetrics
and Gynecology, 117(3), 751-755.
American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women
and the American Society of Addiction Medicine. (2012). Committee Opinion No. 524: Opioid abuse,
dependence, and addiction in pregnancy. Obstetrics and Gynecology, 119(5), 1070-1076.
American Academy of Pediatrics. (in press/embargoed). Testing for drugs of abuse in children and
adolescents. Washington, DC: American Academy of Pediatrics.
Peer-Reviewed References:
Collen, M. (2012). Profit-driven drug testing. Journal of Pain and Palliative Care Pharmacotherapy, 26(1),
13-17.
Compton, Reisfield, et al, The Clinical Tools, Inc. (CTI) Addiction Training Group. 2007
10
http://www.opioidrisk.com/node/489. Accessed May 12, 2014.
Manchikanti, L., Helm, S., Fellows, B., Janata, J. W., et al. (2012). Opioid epidemic in the United States. Pain
Physician, 15(3 Suppl), ES9-ES38.
Reisfield, G.M., Webb, F. J., Bertholf, R. L., Sloan, P.A., & Wilson, G. R. (2007). Family physicians' proficiency
in urine drug test interpretation. Journal of Opioid Management 3(6), 333-337.
Reisfield, G. M., Salazar, E., & Bertholf, R. L. (2007). Rational use and interpretation of urine drug testing in
chronic opioid therapy. Annals of Clinical and Laboratory Sciences, 37(4), 301-314.
Starrels, J. L., Fox, A. D., Kunins, H. V., & Cunningham, C. O. (2012). They don’t know what they don’t know:
Internal medicine residents’ knowledge and confidence in urine drug test interpretation for patients with
chronic pain. Journal of General Internal Medicine, 27(11), 1521-1527.
Substance Abuse and Mental Health Services Administration (SAMSA), Clinical drug testing in primary care,
Technical Assistance Publication Series 32 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance
Abuse and Mental Health Services Administration Center for Substance Abuse Treatment1 Choke Cherry
Road Rockville, MD 20857, HHS Publication No. (SMA) 12-4668, 2012.
Volkow, N. D., & McLellan, T. A. (2011). Curtailing diversion and abuse of opioid analgesics without
jeopardizing pain treatment. JAMA, 305(13), 1346-1347.
http://www.toxicologyunit.com/drug_screen.htm Accessed May 6, 2014.
The Management of Opioid Therapy for Pain Working Group. VA/DoD Clinical Practice Guideline for
Management of Opioid Therapy for Chronic Pain. Department of Veterans Affairs, Department of Defense;
2010.
Quest Diagnostics. (2013). Prescription Drug Misuse in America: A Report on Marijuana and Prescription
Drugs. Quest Diagnostics Health Trends: Prescription Drug Monitoring Report 2013. Available:
http://www.questdiagnostics.com/dms/Documents/healthrends/2013_health_trends_prescription_drug_misuse.pdf.
Clinical Trials:
Treatment Research Institute, National Institute on Drug Abuse (NIDA) Evaluation of Web-based recovery
monitoring with clinical alerts. NCT01465555
http://clinicaltrials.gov/ct2/show/NCT01465555?term=substance+abuse+monitoring&rank=2
California Pacific Medical Center Research Institute, Creare, Inc.
NCT01867476. http://clinicaltrials.gov/ct2/show/NCT01867476?term=substance+abuse+monitoring&rank=
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Centers for Medicare and Medicaid Services (CMS) National Coverage Determination
As of this writing , NDC not found to date.
Local Coverage Determinations:
http://www.cms.gov/medicare-coveragedatabase/shared/handlers/highwire.ashx?url=http://www.cms.gov/medicare-coverage-
11
database/details/lcddetails.aspx@@@LCDId$$$35152***ContrId$$$248&session=w1mnxnf4zoinyxexznl1
5nql&kq=1886886355.
Local Coverage Article: Qualitative Drug Screening-Supplemental Instructions Article
(A48395). http://www.cms.gov/medicare-coverage-database/details/articledetails.aspx?articleId=48395&ver=44&ContrId=178&ContrVer=1&bc=AgCAAAAAAAAAAA%3d%3d&.
LCDL34457: Drugs of abuse testing, 1/25/2014. http://www.cms.gov/medicare-coveragedatabase/details/lcddetails.aspx?LCDId=34457&ContrId=228&ver=3&ContrVer=2&DocID=L34457&bc=gAAAAAgAAAAAAA%3d%3
d&
Local Coverage Determination (LCD): Qualitative Drug Testing (L32050), effective 03/27/2014.
http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=32050&ContrId=161&ver=22&ContrVer=2&Date=&DocID=L32050&bc=iAAAAAgAAAAA
AA%3d%3d&.
Local Coverage Determination (LCD): Qualitative Drug Screening (L28145), effective date 10/25/2013.
http://www.cms.gov/medicare-coverage-database/details/lcd
details.aspx?LCDId=28145&ContrId=269&ver=76&ContrVer=1&Date=&DocID=L28145&bc=iAAAAAgAAAAAA
A%3d%3d&.
Commonly Submitted Codes
Below are the most commonly submitted codes for the service(s) or item(s) subject to this policy. This is not
an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill
accordingly.
CPT Code
80100
80101
80102
Description
Drug screen, qualitative; multiple drug classes, chromatographic method, each
procedure.
Drug screen, qualitative; single drug class method (e.g., immunoassay or
enzyme assay), each drug class.
Drug confirmation, each procedure.
83992
Drug screen, qualitative; multiple drug classes other than chromatographic
method, each procedure.
Column chromatography/mass spectrometry (e.g., GC/MS, or HPLC/MS),
analyte not elsewhere specified; quantitative, single stationary and mobile
phase.
Phencyclidine.
82145
Amphetamines.
82205
Barbiturates.
80154
Benzodiazepines.
83840
Methadone.
G0431
Drug screen, qualitative; multiple drug classes by high-complexity test method
(e.g., immunoassay or enzyme assay), per patient encounter.
80104
82520
Comment
Deleted; not medically
necessary.
Deleted; not medically
necessary.
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G0434
Drug screen, other than chromatographic; any number of drug classes, by
CLIA-waived test or moderate complexity test, per patient encounter.
ICD-9 Code
Description
276.2
Acidosis.
295.00
Simple-type schizophrenia, unspecified state
295.10
Disorganized-type schizophrenia, unspecified state.
295.20
Catatonic-type schizophrenia, unspecified state.
295.30
Paranoid-type schizophrenia, unspecified state.
304.01
Opioid-type dependence, continuous use.
304.90
Unspecified drug dependence, unspecified use.
305.90
Other mixed or unspecified drug abuse, unspecified use.
345.10
Generalized convulsive epilepsy, without intractable epilepsy.
345.11
Generalized convulsive epilepsy, with intractable epilepsy.
345.3
Grand mal status epileptic.
345.90
Epilepsy, unspecified, without intractable epilepsy.
345.91
Epilepsy, unspecified, with intractable epilepsy.
426.10
Atrioventricular block, unspecified.
426.11
First degree atrioventricular block.
426.12
Mobitz (type) ii atrioventricular block.
426.13
Other second degree atrioventricular block.
426.82
Long qt syndrome.
427.0
Paroxysmal supraventricular tachycardia.
427.1
Paroxysmal ventricular tachycardia.
780.01
Coma.
780.09
Alteration of consciousness, other.
780.1
Hallucinations.
780.39
Other convulsions.
780.97
Altered mental status.
963.0
Poisoning by antiallergic and antiemetic drugs.
965.00
Poisoning by opium (alkaloids), unspecified.
965.01
Poisoning by heroin.
965.02
Poisoning by methadone.
965.09
Poisoning by other opiates and related narcotics.
965.1
Poisoning by salicylates.
Comment
13
965.4
Poisoning by aromatic analgesics not elsewhere classified.
965.5
Poisoning by pyrazole derivatives.
965.61
Poisoning by propionic acid derivatives.
966.1
Poisoning by hydantoin derivatives.
967.0
Poisoning by barbiturates.
967.1
Poisoning by chloral hydrate group.
967.2
Poisoning by paraldehyde.
967.3
Poisoning by bromine compounds.
967.4
Poisoning by methaqualone compounds.
967.5
Poisoning by glutethimide group.
967.6
Poisoning by mixed sedatives not elsewhere classified.
967.8
Poisoning by other sedatives and hypnotics.
967.9
Poisoning by unspecified sedative or hypnotic.
969.00
Poisoning by antidepressant, unspecified.
969.01
Poisoning by monoamine oxidase inhibitors.
969.02
Poisoning by selective serotonin and norepinephrine reuptake inhibitors.
969.03
Poisoning by selective serotonin reuptake inhibitors.
969.04
Poisoning by tetracyclic antidepressants.
969.05
Poisoning by tricyclic antidepressants.
969.09
Poisoning by other antidepressants.
969.1
Poisoning by phenothiazine-based tranquilizers.
969.2
Poisoning by butyrophenone-based tranquilizers.
969.3
Poisoning by other antipsychotics, neuroleptics and major tranquilizers.
969.4
Poisoning by benzodiazepine-based tranquilizers.
969.5
Poisoning by other tranquilizers.
969.6
Poisoning by psychodysleptics (hallucinogens).
969.70
Poisoning by psychostimulant, unspecified.
969.71
Poisoning by caffeine.
969.72
Poisoning by amphetamines.
969.73
Poisoning by methylphenidate.
969.79
Poisoning by other psychostimulants.
969.8
Poisoning by other specified psychotropic agents.
969.9
Poisoning by unspecified psychotropic agent.
970.81
Poisoning by cocaine.
970.89
Poisoning by other central nervous system stimulants.
14
972.1
Poisoning by cardiotonic glycosides and drugs of similar action.
977.9
Poisoning by unspecified drug or medicinal substance.
V15.81
V58.69
Personal history of noncompliance with medical treatment presenting hazards
to health.
Long-term (current) use of other medications.
ICD-10 Code
Description
Comment
HCPCS Level
II
Description
Comment
N/A
15

Quantitative and Qualitative Drug Screens for Illicit Use of

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