WSI has expectations for presumptive drug screening and definitive testing, based on adopted medical guidelines. Reimbursement for these drug tests is dependent upon a provider’s compliance with these expectations. Non-compliance with the expectations may affect the reimbursement of other medical services.
Drug screens and testing are important to the claim management process as they are helpful in evaluating the following:
- Worker is taking prescribed medications that are at or below therapeutic or toxic levels (therapeutic drug monitoring); or
- Worker is taking prescribed controlled substance medications; or
- Worker is taking non-prescribed or illicit drugs.
The two main methods of drug testing include initial qualitative (presumptive) screenings and confirmatory quantitative (definitive) testing. Presumptive screenings are either laboratory-based or point of collection (POC) testing, and drugs are reported as only either present or absent. Definitive tests are highly sensitive and specific to a particular drug(s) or class of drugs.
There are many limitations of presumptive drug screenings, which necessitate the use of definitive testing for certain circumstances. The Work Loss Data Institute’s Official Disability Guidelines (ODG), adopted by WSI, details the following on when to perform definitive testing: “When the POC screen is appropriate for the prescribed drugs without evidence of non-prescribed substances, confirmation is generally not required. Confirmation should be sought for (1) all samples testing negative for prescribed drugs, (2) all samples positive for non-prescribed opioids and (3) all samples positive for illicit drugs.”
It is WSI’s expectation that a provider will perform presumptive screening when medically necessary and prior to any definitive testing. In addition, WSI expects definitive testing on all samples positive for non-prescribed opioids and all samples positive for illicit drugs. Failure, neglect, or refusal to respond to requests by WSI for drug testing may result in the denial of reimbursement for medical services provided, see North Dakota Administrative Code § 92-01-02-31.5(c).
WSI follows CMS standards for the billing of drug screens and testing services. A provider may bill one presumptive drug screening code (CPT 80305-80307) per day. In the event of a positive presumptive drug screen, a provider may bill one definitive drug testing code (CPT G0480-G0483) per day.