Urinary Drug Screen Notification
Date: 02/17/17
Magnolia Health is committed to our members receiving high quality care at the right location and at the right time. We would like to inform our providers that beginning on January 1, 2017, there have been changes in the coding of urinary drug screens due to CMS regulations. As of this date, the codes G0477, G0478, and G0479 for presumptive/qualitative urinary drug screens have been replaced and will no longer be reimbursed. The new codes replacing these codes will be 80305, 80306, and 80307 which are currently being reimbursed. The codes for definitive/quantitative testing (G0480-G0483) remain unchanged and continue to be reimbursed when medically necessary.
With these new changes Magnolia Health will be removing prior authorization requirements for presumptive/qualitative urinary drug screens with a limit of 12 per members per year. Definitive/quantitative urinary drug screens will continue to require prior authorization to determine medical necessity. Medical necessity can be demonstrated by documentation containing one or more of the following conditions:
A. Member has a documented history or suspicion of illicit or prescription drug use or noncompliance or a high probability of non-adherence to a prescribed drug regimen documented in the medical record; and all of the following:
1. A preliminary drug test has been previously performed; and
2. The findings from that preliminary test (either positive or negative) are either:
a. Inconsistent with the expected results as suggested by the member's medical history, clinical presentation, and/or member's own statement after a detailed discussion about their recent medication and drug use, or
b.The test yielded results consistent with the clinical scenario but drug class-specific assays are needed to identify the precise drug(s) that resulted in the positive test result; and
3. Resolving the inconsistency is essential to the ongoing care of the member; and
The requested confirmatory/definitive test is only for the specific drug(s) or number of drug classes for which preliminary analysis has yielded unexpected results.
OR
B. The request is for a serum therapeutic drug level in relation to the medical treatment of a disease or condition (e.g. phenobarbital level in the treatment of seizures).
Please call Magnolia Health for any questions.