Definitive Drug Test Targeted Probe and Educate Review Results

The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCSPCS G0482 & G0483 – Drug Test, Definitive. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:

Top Denial Reasons

  • Service was Down-coded Two Levels
  • Service was Down-coded One Level
  • Documentation does not Support Medical Necessity

Educational Resources



Local Coverage Determination L36668 "Lab: Controlled Substance Monitoring and Drugs of Abuse Testing" discusses the coverage requirements for these services. Definitive drug testing assists providers in the monitoring and managing a patient’s treatment by providing a means to assess for the presence or absence of medications currently being taken by the patient. Documentation must support the reason and frequency of the ordered testing. Although presumptive urine drug testing is helpful in screening for drug classes, definitive testing identifies specific drugs, metabolites and illicit substances. Documentation must reflect why definitive testing is medically necessary for treating the patient. The following are indications definitive urine drug testing would be considered reasonable and necessary:

  • “Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT;”
  • “Definitively identify specific drugs in a large family of drugs;”
  • “Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs;”
  • “Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation of THC uses according to a treatment plan);”
  • “Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient’s self-report, presentation, medical history, or current prescribed pain medication plan;”
  • “Rule out an error as the cause of a presumptive UDT result;”
  • “Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and”
  • “Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions.”
  • The frequency of repeat definitive drug testing must be appropriate for the patient, underlying condition, and circumstance.

Refer to:

Correct Coding

If documentation indicates it supports a higher or lower level code, the claim will be up or down coded as indicated. Proper coding is necessary on Medicare claims because codes are generally used in determining coverage and payment amounts. CMS accepts only HIPAA approved ICD-9-CM or ICD-10-CM/ICD-10-PCS codes, depending on the date of service.

The Current Procedural Terminology (CPT®) Manual and Healthcare Common Procedure Coding System (HCPCS) Manual are listings of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of the terminology is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby provides an effective means for reliable nationwide communication among physicians, patients, and third parties. The name of the procedure or service that most accurately identifies the service performed and documented in the medical record should be selected.  Inclusion of a descriptor and its associated five digit identifying code number in the CPT® and HCPCS manual is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations.

It is the responsibility of providers to be familiar with the descriptive terms and identify the most appropriate and comprehensive CPT® or HCPCS codes for reporting medical procedures and services. The complete, descriptive documentation of all services rendered is absolutely necessary in order for a claim to be properly evaluated. Medical Review will continue to correct claims based on the submitted documentation if billing is found to be incorrect.

Services provided by your facility are expected to be billed in compliance with CMS claims processing guidelines. Medical Review will continue to correct claims based on the submitted documentation if billing is found to be incorrect. Noted continued billing errors may be referred to the Provider Outreach and Education (POE) representatives for education on proper billing in accordance with CMS requirements. If a provider is consistently billing incorrectly, this may be highlighted for review and possible referral to the Unified Program Integrity Contractor (UPIC) for potential compliance or abuse issue.

Refer to: Title XVIII of the Social Security Act, Section 1833(e), Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section, and IOM, Pub 100-04, Medicare Claims Processing Manual, Chapters 12 and 23.


Last Updated Tue, 21 Sep 2021 15:04:31 +0000