2020 MEDICARE LOCAL COVERAGE ARTICLE (LCA) - A55001 PROCEDURE CODES: G0480, G0481, G0482, G0483, G0659, 80305, 80306, 80307 Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing For services performed on or after 6-28-2016 DLS TEST CODE AND NAME 1203 SALICYLATES 2236 IMIPRAMINE & DESIPRAMINE 2857 TOX - SAP 7AB 3557 TOX - SAP 5A 39176 CLORAZEPATE 4008 NORTRIPTYLINE 40087 GC/MS NIDA LAB 41787 TOX - SAP 6BO 41797 TOX - SAP 7 ABO 41849 DIAZEPAM AND METABOLITE 41919 ANTIDEPRESSANTS SCREEN, URINE 41929 ANTIDEPRESSANTS CONFIRMATION, URINE 41970 NICOTINE AND METABOLITES 43327 SUBSTANCE IDENTIFICATION 43357 ETHANOL 45517 NIDA 5, GC/MS 46047 AMPHETAMINE D,L SEP NIDA 46057 ETHANOL, CLINICAL URINE 46827 TOX - SAP 6 NG 47163 MECONIUM (MEC STAT-5) 47267 TOX - SAP 9A, GC/MS 47277 TOX - SAP 11A, GC/MS 47287 TOX - SAP 5, GC/MS 47297 TOX - SAP 10 47307 TOX - SAP 11A 47317 CLINICAL SUBSTANCE ABUSE PANEL 5 47327 CLINICAL SUBSTANCE ABUSE PANEL 7 47337 CLINICAL SUBSTANCE ABUSE PANEL 9A 47347 CLINICAL SUBSTANCE ABUSE PANEL 10 47357 CLINICAL SUBSTANCE ABUSE PANEL 10A 47367 CLINICAL SUBSTANCE ABUSE PANEL 11A 47377 TOX - SAP 10, GC/MS 47387 TOX - SAP 5A,GC/MS 47397 TOX - SAP 6, GC/MS 47407 TOX - SAP 7, GC/MS 47417 TOX - SAP 7A, GC/MS 47427 TOX - SAP 4, GC/MS 47846 COMPREHENSIVE URINE DRUG SCREEN 49150 COCAINE / AMPHETAMINE URINE SCRN 49177 6-MONOACETYLMORPHINE Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 1 of 13 49237 AMPHETAMINES, CLINICAL UR 49247 BARBITURATES, CLINICAL URINE 49257 BENZODIAZEPINES, CLINICAL URINE 49267 COCAINE METABOLITE 49277 METHADONE, CLINICAL URINE 49287 OPIATES, CLINICAL UR 49297 PHENCYCLIDINE, CLINICAL UR 49307 PROPOXYPHENE, CLINICAL UR 49317 THC, CLINICAL UR 49347 PROPOXYPHENE, URINE CONFIRMATION 49569 FELBAMATE 49689 IBUPROFEN 49729 HYPOGLYCEMIC PANEL 49739 TEMAZEPAM (RESTORIL) 504716 DRUGS OF ABUSE SCREEN (7 PANEL), MECONIUM 50439 HYDROCODONE AND METABOLITES 50449 OXYCODONE & METABOLITE 50459 ALPRAZOLAM AND METABOLITE 508100 URINE DRUG SCREEN, #2 (MEDICAL) 51419 NICOTINE AND COTININE - URINE 51717 TOX - SAP 5 LP, GC/MS 52699 ETHYL GLUCURONIDE, RANDOM URINE 54697 TOX - SAP 5, GC/MS POC 54767 TOX - SAP 5, POC 54847 TOX - SAP 4 W/O THC, GC/MS 55437 TOX - SAP 6 X 55447 TOX - SAP 11 X 55757 CLINICAL SUBSTANCE ABUSE PANEL 11 E 56140 MDMA, URINE CONFIRMATION 56747 TOX - SAP 5, GC/MS-DISC 58279 DRUGS OF ABUSE 2 (AMPHETAMINES) 58289 DRUGS OF ABUSE 3 (BARBITURATES) 58299 DRUGS OF ABUSE 4 (BENZODIAZEPINES) 58319 DRUGS OF ABUSE 5 (COCAINE & METABOLITE) 58329 DRUGS OF ABUSE 6 (OPIATES) 58339 DRUGS OF ABUSE 7 (OXYCODONE) 58359 DRUGS OF ABUSE 9 (THC METABOLITES) 58369 DRUGS OF ABUSE 10 (METHADONE) 58379 DRUGS OF ABUSE 11 (PROPOXYPHENE) 58687 CLINICAL SUBSTANCE ABUSE PANEL 8 OX 58907 6-ACETYLMORPHINE, UR. SCRN, CLINICAL 58917 6-ACETYLMORPHINE UR. SCRN FORENSIC 58927 HYDROCODONE, UR. SCRN, CLINICAL 58937 BUPRENORPHINE, URINE SCREEN 59847 TOX - SAP 6AB, INTAKE 59857 EXPANDED OPIATES 60119 PHOSPHATIDYLETHANOL (PETH) 61917 TOX - SAP 9, GC/MS 63708 ETHYL GLUCURONIDE, RANDOM URINE 64237 OXYCODONE, CLINICAL URINE 64247 TOX - CLINICAL SAP 6 OA 64257 TOX - CLINICAL SAP 8 OA 64267 TOX - CLINICAL SAP 10 OA 64277 TOX - CLINICAL SAP 11 OA 66387 TOX - SAP 5 D, GC/MS Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 2 of 13 66430 EXPANDED OPIATES, GC/MS URINE 67347 TOX - CLINICAL SAP 10 XO 67377 MDMA (ECSTACY), URINE SCREEN 6988 DESIPRAMINE 7013 ACETAMINOPHEN (TYLENOL) 7026 AMITRIPTYLINE & NORTRIPTYLINE 71190 NICOTINE AND COTININE 71200 COMPREHENSIVE DRUG SCREEN, SERUM 71887 SAP 4 GC/MS, REF 71897 SAP 10 GC/MS, REF 71949 SYNTHETIC CANNABINOID METAB., URINE 72207 ETHYL GLUCURONIDE, URINE SCREEN 72217 TOX - SAP 7A, INTAKE 72257 ETHYL GLUCURONIDE, URINE CONFIRMATION 7257 CLINICAL SUBSTANCE ABUSE PANEL 8A 7577 AMPHETAMINE/METH, URINE CONFIRMATION 76207 SYNTHETIC CANNABINOIDS SCREEN, BLOOD 76217 NPS SCREEN 1, BLOOD 76227 NPS SCREEN 2, BLOOD 76257 NOVEL PSYCHOACTIVE SUB. SCREEN, URINE 7677 BENZODIAZEPINES, URINE CONFIRMATION 7727 METHAMPHETAMINE, CHIRAL CONFIRM 7847 METHAQUALONE, URINE CONFIRMATION 7877 COCAINE, URINE CONFIRMATION 7927 OPIATES, CONFIRM - URINE 7998 CLONAZEPAM 8007 THC, CONFIRM, URINE 8095 TOX - SAP 7 8107 URINE DRUG SCREEN, #2 (MEDICAL) 8108 URINE DRUG SCREEN, #2 (MEDICAL) 8113 DRUG SCREEN # 4 (MEDICAL) 8115 TOX - SAP 4 8118 DRUG SCREEN # 4 (MEDICAL) 8199 TRAZODONE 8207 URINE DRUG SCREEN, #2 (MEDICAL) 8227 BUPRENORPHINE CONFIRMATION, URINE 8347 METHAQUALONE, URINE FORENSIC SCREEN 8737 METHADONE, URINE CONFIRMATION 8747 BARBITURATES, URINE CONFIRMATION 8767 METHADONE, URINE FORENSIC SCREEN 8777 BENZODIAZEPINES, URINE FORENSIC SCREEN 8797 ETHANOL, URINE FORENSIC SCREEN 8855 CLINICAL SUBSTANCE ABUSE PANEL 5A ICD-10 CODE DESCRIPTION E87.2 Acidosis F10.11 Alcohol abuse, in remission F10.130 Alcohol abuse with withdrawal, uncomplicated F10.131 Alcohol abuse with withdrawal delirium F10.132 Alcohol abuse with withdrawal with perceptual disturbance F10.20 Alcohol dependence, uncomplicated F11.11 Opioid abuse, in remission F11.13 Opioid abuse with withdrawal F11.20 Opioid dependence, uncomplicated Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 3 of 13 ICD-10 CODE DESCRIPTION F11.220 Opioid dependence with intoxication, uncomplicated F11.221 Opioid dependence with intoxication delirium F11.222 Opioid dependence with intoxication with perceptual disturbance F11.229 Opioid dependence with intoxication, unspecified F11.23 Opioid dependence with withdrawal F11.24 Opioid dependence with opioid-induced mood disorder F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified F11.281 Opioid dependence with opioid-induced sexual dysfunction F11.282 Opioid dependence with opioid-induced sleep disorder F11.288 Opioid dependence with other opioid-induced disorder F11.29 Opioid dependence with unspecified opioid-induced disorder F12.11 Cannabis abuse, in remission F12.13 Cannabis abuse with withdrawal F12.23 Cannabis dependence with withdrawal F12.93 Cannabis use, unspecified with withdrawal F13.11 Sedative, hypnotic or anxiolytic abuse, in remission F13.130 Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated F13.131 Sedative, hypnotic or anxiolytic abuse with withdrawal delirium F13.132 Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance F14.11 Cocaine abuse, in remission F14.13 Cocaine abuse, unspecified with withdrawal F14.93 Cocaine use, unspecified with withdrawal F15.11 Other stimulant abuse, in remission F15.13 Other stimulant abuse with withdrawal F16.11 Hallucinogen abuse, in remission F18.10 Inhalant abuse, uncomplicated F18.11 Inhalant abuse, in remission F18.120 Inhalant abuse with intoxication, uncomplicated F18.90 Inhalant use, unspecified, uncomplicated F19.11 Other psychoactive substance abuse, in remission F19.130 Other psychoactive substance abuse with withdrawal, uncomplicated F19.131 Other psychoactive substance abuse with withdrawal delirium F19.132 Other psychoactive substance abuse with withdrawal with perceptual disturbance F19.20 Other psychoactive substance dependence, uncomplicated F20.0 Paranoid schizophrenia F20.1 Disorganized schizophrenia F20.2 Catatonic schizophrenia F20.89 Other schizophrenia F55.0 Abuse of antacids F55.1 Abuse of herbal or folk remedies F55.2 Abuse of laxatives F55.3 Abuse of steroids or hormones F55.4 Abuse of vitamins F55.8 Abuse of other non-psychoactive substances Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G40.301 epilepticus Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status G40.309 epilepticus Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 4 of 13 ICD-10 CODE DESCRIPTION G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status G40.319 epilepticus G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus Other generalized epilepsy and epileptic syndromes, not intractable, without status G40.409 epilepticus G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus G40.42 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder G40.901 Epilepsy, unspecified, not intractable, with status epilepticus G40.909 Epilepsy, unspecified, not intractable, without status epilepticus G40.911 Epilepsy, unspecified, intractable, with status epilepticus G40.919 Epilepsy, unspecified, intractable, without status epilepticus G89.29 Other chronic pain G89.4 Chronic pain syndrome I44.0 Atrioventricular block, first degree I44.1 Atrioventricular block, second degree I44.30 Unspecified atrioventricular block I45.81 Long QT syndrome I47.0 Re-entry ventricular arrhythmia I47.1 Supraventricular tachycardia I47.2 Ventricular tachycardia I49.2 Junctional premature depolarization M25.50 Pain in unspecified joint M25.511 Pain in right shoulder M25.512 Pain in left shoulder M25.59 Pain in other specified joint M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region M47.22