Draft Local Coverage Article Billing and Coding

Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing

DA57077

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
A57077
Draft Article ID
DA57077
Draft Article Title
Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing
Article Type
Billing and Coding
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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services:

  • Chapter 10 Pathology/Laboratory Services,
    • Section E. Drug Testing
    • Section M. Medically Unlikely Edits (MUEs)
    • Section N. General Policy Statements

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL36393 Controlled Substance Monitoring and Drugs of Abuse Testing. Please refer to the LCD for reasonable and necessary requirements and limitations.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Per the NCCI Policy Manual, Chapter 10, Section E-Drug Testing, providers performing validity testing on urine specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed.

CPT/HCPCS codes that describe a specific number of drugs/metabolites/substances (rather than number of drug classes) (e.g., 25 drug panel) will be non-covered until documentation is provided demonstrating both 1) to which class each of these analytes belong and 2) all classes represented by the analytes are listed as covered by the LCD (14 specific classes described and allowed). If documentation is provided on redetermination demonstrating that the panel only tests analytes belonging to covered drug classes, the article will be updated accordingly.

Utilization Parameters

Medicare will only pay for one presumptive test result per patient per date of service regardless of the number of billing providers.

Medicare will only pay for one definitive test result per patient per date of service regardless of the number of billing providers.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. For patients in active treatment for substance use disorder or monitoring across different phases of recovery or patients receiving chronic pain management, the medical record must include:

    • Medical history and physical examination
    • Rationale for testing (i.e., how results will be used to direct care) and the rationale for the drug/drug classes/metabolites ordered
    • Diagnostic, therapeutic, and laboratory results
    • Evaluations and consultations
    • Treatment objectives
    • Risk assessment plan
    • Discussion of risks, benefits, and limitations of treatments
    • Details of different treatments and medications, including date, type, dosage, and quantity prescribed
    • Instructions to the patient
    • Periodic reviews of outcomes, including documentation of functional status, preferably using validated tools
  1. For patients in the urgent care/emergency department setting, the medical record must include:
    • Medical history and physical examination
    • Rationale for testing (i.e., how results will be used to direct care) and the rationale for the drug/drug classes/metabolites ordered
    • Diagnostic, therapeutic, and laboratory results
    • Evaluations and consultations
  1. Urine drug test orders must include a list of ALL prescribed medications and ALL over-the-counter medications/supplements/herbal products taken by the patient (not just medications prescribed by the ordering provider since other medications/supplements/herbal products can cross react and cause false positives).

Coding Information

CPT/HCPCS Codes

Group 1

(6 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
80305 Drug test prsmv dir opt obs
80306 Drug test prsmv instrmnt
80307 Drug test prsmv chem anlyzr
G0480 Drug test def 1-7 classes
G0481 Drug test def 8-14 classes
0007U Rx test prsmv ur w/def conf

Group 2

(16 Codes)
Group 2 Paragraph

Consistent with the LCD, the following CPT/HCPCS codes are Non-Covered:

Group 2 Codes
CodeDescription
G0482 Drug test def 15-21 classes
G0483 Drug test def 22+ classes
G0659 Drug test def simple all cl
0051U Rx mntr lc-ms/ms ur/bld 31
0082U Rx test def 90+ rx/sbsts ur
0093U Rx mntr 65 com drugs urine
0143U Drug assay 120+ rx/metablt
0144U Drug assay 160+ rx/metablt
0145U Drug assay 65+ rx/metablt
0146U Drug assay 80+ rx/metablt
0147U Drug assay 85+ rx/metablt
0148U Drug assay 100+ rx/metablt
0149U Drug assay 60+ rx/metablt
0150U Drug assay 120+ rx/metablt
0227U Rx asy prsmv 30+rx/metablt
0328U Drug assay 120+ rx&metablt

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(396 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Labs are not to pre-populate requisition forms with diagnosis codes.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS codes: 80305, 80306, 80307, G0480, G0481 and 0007U.

Group 1 Codes
CodeDescription
E87.21 Acute metabolic acidosis
E87.22 Chronic metabolic acidosis
E87.29 Other acidosis
E87.3 Alkalosis
E87.4 Mixed disorder of acid-base balance
F11.10 Opioid abuse, uncomplicated
F11.120 Opioid abuse with intoxication, uncomplicated
F11.121 Opioid abuse with intoxication delirium
F11.122 Opioid abuse with intoxication with perceptual disturbance
F11.13 Opioid abuse with withdrawal
F11.14 Opioid abuse with opioid-induced mood disorder
F11.150 Opioid abuse with opioid-induced psychotic disorder with delusions
F11.151 Opioid abuse with opioid-induced psychotic disorder with hallucinations
F11.181 Opioid abuse with opioid-induced sexual dysfunction
F11.182 Opioid abuse with opioid-induced sleep disorder
F11.188 Opioid abuse with other opioid-induced disorder
F11.20 Opioid dependence, uncomplicated
F11.220 Opioid dependence with intoxication, uncomplicated
F11.221 Opioid dependence with intoxication delirium
F11.222 Opioid dependence with intoxication with perceptual disturbance
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
F11.281 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
F12.10 Cannabis abuse, uncomplicated
F12.120 Cannabis abuse with intoxication, uncomplicated
F12.121 Cannabis abuse with intoxication delirium
F12.122 Cannabis abuse with intoxication with perceptual disturbance
F12.13 Cannabis abuse with withdrawal
F12.150 Cannabis abuse with psychotic disorder with delusions
F12.151 Cannabis abuse with psychotic disorder with hallucinations
F12.180 Cannabis abuse with cannabis-induced anxiety disorder
F12.188 Cannabis abuse with other cannabis-induced disorder
F12.20 Cannabis dependence, uncomplicated
F12.220 Cannabis dependence with intoxication, uncomplicated
F12.221 Cannabis dependence with intoxication delirium
F12.222 Cannabis dependence with intoxication with perceptual disturbance
F12.23 Cannabis dependence with withdrawal
F12.250 Cannabis dependence with psychotic disorder with delusions
F12.251 Cannabis dependence with psychotic disorder with hallucinations
F12.280 Cannabis dependence with cannabis-induced anxiety disorder
F12.288 Cannabis dependence with other cannabis-induced disorder
F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
F13.120 Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated
F13.121 Sedative, hypnotic or anxiolytic abuse with intoxication delirium
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
F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced mood disorder
F13.150 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions
F13.151 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations
F13.180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced anxiety disorder
F13.181 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sexual dysfunction
F13.182 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-induced disorder
F13.20 Sedative, hypnotic or anxiolytic dependence, uncomplicated
F13.220 Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated
F13.221 Sedative, hypnotic or anxiolytic dependence with intoxication delirium
F13.230 Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated
F13.231 Sedative, hypnotic or anxiolytic dependence with withdrawal delirium
F13.232 Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance
F13.24 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorder
F13.250 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions
F13.251 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations
F13.26 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder
F13.27 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia
F13.280 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder
F13.281 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunction
F13.282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.288 Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder
F14.10 Cocaine abuse, uncomplicated
F14.120 Cocaine abuse with intoxication, uncomplicated
F14.121 Cocaine abuse with intoxication with delirium
F14.122 Cocaine abuse with intoxication with perceptual disturbance
F14.13 Cocaine abuse, unspecified with withdrawal
F14.14 Cocaine abuse with cocaine-induced mood disorder
F14.150 Cocaine abuse with cocaine-induced psychotic disorder with delusions
F14.151 Cocaine abuse with cocaine-induced psychotic disorder with hallucinations
F14.180 Cocaine abuse with cocaine-induced anxiety disorder
F14.181 Cocaine abuse with cocaine-induced sexual dysfunction
F14.182 Cocaine abuse with cocaine-induced sleep disorder
F14.188 Cocaine abuse with other cocaine-induced disorder
F14.20 Cocaine dependence, uncomplicated
F14.220 Cocaine dependence with intoxication, uncomplicated
F14.221 Cocaine dependence with intoxication delirium
F14.222 Cocaine dependence with intoxication with perceptual disturbance
F14.23 Cocaine dependence with withdrawal
F14.24 Cocaine dependence with cocaine-induced mood disorder
F14.250 Cocaine dependence with cocaine-induced psychotic disorder with delusions
F14.251 Cocaine dependence with cocaine-induced psychotic disorder with hallucinations
F14.280 Cocaine dependence with cocaine-induced anxiety disorder
F14.281 Cocaine dependence with cocaine-induced sexual dysfunction
F14.282 Cocaine dependence with cocaine-induced sleep disorder
F14.288 Cocaine dependence with other cocaine-induced disorder
F15.10 Other stimulant abuse, uncomplicated
F15.120 Other stimulant abuse with intoxication, uncomplicated
F15.121 Other stimulant abuse with intoxication delirium
F15.122 Other stimulant abuse with intoxication with perceptual disturbance
F15.13 Other stimulant abuse with withdrawal
F15.14 Other stimulant abuse with stimulant-induced mood disorder
F15.150 Other stimulant abuse with stimulant-induced psychotic disorder with delusions
F15.151 Other stimulant abuse with stimulant-induced psychotic disorder with hallucinations
F15.180 Other stimulant abuse with stimulant-induced anxiety disorder
F15.181 Other stimulant abuse with stimulant-induced sexual dysfunction
F15.182 Other stimulant abuse with stimulant-induced sleep disorder
F15.188 Other stimulant abuse with other stimulant-induced disorder
F15.20 Other stimulant dependence, uncomplicated
F15.220 Other stimulant dependence with intoxication, uncomplicated
F15.221 Other stimulant dependence with intoxication delirium
F15.222 Other stimulant dependence with intoxication with perceptual disturbance
F15.23 Other stimulant dependence with withdrawal
F15.24 Other stimulant dependence with stimulant-induced mood disorder
F15.250 Other stimulant dependence with stimulant-induced psychotic disorder with delusions
F15.251 Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations
F15.280 Other stimulant dependence with stimulant-induced anxiety disorder
F15.281 Other stimulant dependence with stimulant-induced sexual dysfunction
F15.282 Other stimulant dependence with stimulant-induced sleep disorder
F15.288 Other stimulant dependence with other stimulant-induced disorder
F16.10 Hallucinogen abuse, uncomplicated
F16.120 Hallucinogen abuse with intoxication, uncomplicated
F16.121 Hallucinogen abuse with intoxication with delirium
F16.122 Hallucinogen abuse with intoxication with perceptual disturbance
F16.14 Hallucinogen abuse with hallucinogen-induced mood disorder
F16.150 Hallucinogen abuse with hallucinogen-induced psychotic disorder with delusions
F16.151 Hallucinogen abuse with hallucinogen-induced psychotic disorder with hallucinations
F16.180 Hallucinogen abuse with hallucinogen-induced anxiety disorder
F16.183 Hallucinogen abuse with hallucinogen persisting perception disorder (flashbacks)
F16.188 Hallucinogen abuse with other hallucinogen-induced disorder
F16.20 Hallucinogen dependence, uncomplicated
F16.220 Hallucinogen dependence with intoxication, uncomplicated
F16.221 Hallucinogen dependence with intoxication with delirium
F16.24 Hallucinogen dependence with hallucinogen-induced mood disorder
F16.250 Hallucinogen dependence with hallucinogen-induced psychotic disorder with delusions
F16.251 Hallucinogen dependence with hallucinogen-induced psychotic disorder with hallucinations
F16.280 Hallucinogen dependence with hallucinogen-induced anxiety disorder
F16.283 Hallucinogen dependence with hallucinogen persisting perception disorder (flashbacks)
F16.288 Hallucinogen dependence with other hallucinogen-induced disorder
F18.10 Inhalant abuse, uncomplicated
F18.120 Inhalant abuse with intoxication, uncomplicated
F18.121 Inhalant abuse with intoxication delirium
F18.14 Inhalant abuse with inhalant-induced mood disorder
F18.150 Inhalant abuse with inhalant-induced psychotic disorder with delusions
F18.151 Inhalant abuse with inhalant-induced psychotic disorder with hallucinations
F18.17 Inhalant abuse with inhalant-induced dementia
F18.180 Inhalant abuse with inhalant-induced anxiety disorder
F18.188 Inhalant abuse with other inhalant-induced disorder
F18.20 Inhalant dependence, uncomplicated
F18.220 Inhalant dependence with intoxication, uncomplicated
F18.221 Inhalant dependence with intoxication delirium
F18.24 Inhalant dependence with inhalant-induced mood disorder
F18.250 Inhalant dependence with inhalant-induced psychotic disorder with delusions
F18.251 Inhalant dependence with inhalant-induced psychotic disorder with hallucinations
F18.27 Inhalant dependence with inhalant-induced dementia
F18.280 Inhalant dependence with inhalant-induced anxiety disorder
F18.288 Inhalant dependence with other inhalant-induced disorder
F19.10 Other psychoactive substance abuse, uncomplicated
F19.120 Other psychoactive substance abuse with intoxication, uncomplicated
F19.121 Other psychoactive substance abuse with intoxication delirium
F19.122 Other psychoactive substance abuse with intoxication with perceptual disturbances
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
F19.14 Other psychoactive substance abuse with psychoactive substance-induced mood disorder
F19.150 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions
F19.151 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallucinations
F19.16 Other psychoactive substance abuse with psychoactive substance-induced persisting amnestic disorder
F19.17 Other psychoactive substance abuse with psychoactive substance-induced persisting dementia
F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder
F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction
F19.182 Other psychoactive substance abuse with psychoactive substance-induced sleep disorder
F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder
F19.20 Other psychoactive substance dependence, uncomplicated
F19.220 Other psychoactive substance dependence with intoxication, uncomplicated
F19.221 Other psychoactive substance dependence with intoxication delirium
F19.222 Other psychoactive substance dependence with intoxication with perceptual disturbance
F19.230 Other psychoactive substance dependence with withdrawal, uncomplicated
F19.231 Other psychoactive substance dependence with withdrawal delirium
F19.232 Other psychoactive substance dependence with withdrawal with perceptual disturbance
F19.24 Other psychoactive substance dependence with psychoactive substance-induced mood disorder
F19.250 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions
F19.251 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations
F19.26 Other psychoactive substance dependence with psychoactive substance-induced persisting amnestic disorder
F19.27 Other psychoactive substance dependence with psychoactive substance-induced persisting dementia
F19.280 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder
F19.281 Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction
F19.282 Other psychoactive substance dependence with psychoactive substance-induced sleep disorder
F19.288 Other psychoactive substance dependence with other psychoactive substance-induced disorder
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status 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
G40.501 Epileptic seizures related to external causes, not intractable, with status epilepticus
G40.509 Epileptic seizures related to external causes, not intractable, without status epilepticus
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
I44.0 Atrioventricular block, first degree
I44.1 Atrioventricular block, second degree
I45.81 Long QT syndrome
I47.0 Re-entry ventricular arrhythmia
I47.1 Supraventricular tachycardia
I47.21 Torsades de pointes
I47.29 Other ventricular tachycardia
I49.2 Junctional premature depolarization
R40.0 Somnolence
R40.1 Stupor
R40.4 Transient alteration of awareness
R41.82 Altered mental status, unspecified
R44.0 Auditory hallucinations
R44.1 Visual hallucinations
R44.2 Other hallucinations
R56.9 Unspecified convulsions
T38.7X1A Poisoning by androgens and anabolic congeners, accidental (unintentional), initial encounter
T38.7X2A Poisoning by androgens and anabolic congeners, intentional self-harm, initial encounter
T38.7X3A Poisoning by androgens and anabolic congeners, assault, initial encounter
T38.7X4A Poisoning by androgens and anabolic congeners, undetermined, initial encounter
T39.011A Poisoning by aspirin, accidental (unintentional), initial encounter
T39.012A Poisoning by aspirin, intentional self-harm, initial encounter
T39.013A Poisoning by aspirin, assault, initial encounter
T39.014A Poisoning by aspirin, undetermined, initial encounter
T39.091A Poisoning by salicylates, accidental (unintentional), initial encounter
T39.092A Poisoning by salicylates, intentional self-harm, initial encounter
T39.093A Poisoning by salicylates, assault, initial encounter
T39.094A Poisoning by salicylates, undetermined, initial encounter
T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental (unintentional), initial encounter
T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter
T39.1X3A Poisoning by 4-Aminophenol derivatives, assault, initial encounter
T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial encounter
T39.2X1A Poisoning by pyrazolone derivatives, accidental (unintentional), initial encounter
T39.2X2A Poisoning by pyrazolone derivatives, intentional self-harm, initial encounter
T39.2X3A Poisoning by pyrazolone derivatives, assault, initial encounter
T39.2X4A Poisoning by pyrazolone derivatives, undetermined, initial encounter
T39.311A Poisoning by propionic acid derivatives, accidental (unintentional), initial encounter
T39.312A Poisoning by propionic acid derivatives, intentional self-harm, initial encounter
T39.313A Poisoning by propionic acid derivatives, assault, initial encounter
T39.314A Poisoning by propionic acid derivatives, undetermined, initial encounter
T39.391A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], accidental (unintentional), initial encounter
T39.392A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], intentional self-harm, initial encounter
T39.393A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], assault, initial encounter
T39.394A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], undetermined, initial encounter
T40.0X1A Poisoning by opium, accidental (unintentional), initial encounter
T40.0X2A Poisoning by opium, intentional self-harm, initial encounter
T40.0X3A Poisoning by opium, assault, initial encounter
T40.0X4A Poisoning by opium, undetermined, initial encounter
T40.1X1A Poisoning by heroin, accidental (unintentional), initial encounter
T40.1X2A Poisoning by heroin, intentional self-harm, initial encounter
T40.1X3A Poisoning by heroin, assault, initial encounter
T40.1X4A Poisoning by heroin, undetermined, initial encounter
T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter
T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter
T40.2X3A Poisoning by other opioids, assault, initial encounter
T40.2X4A Poisoning by other opioids, undetermined, initial encounter
T40.3X1A Poisoning by methadone, accidental (unintentional), initial encounter
T40.3X2A Poisoning by methadone, intentional self-harm, initial encounter
T40.3X3A Poisoning by methadone, assault, initial encounter
T40.3X4A Poisoning by methadone, undetermined, initial encounter
T40.411A Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter
T40.412A Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter
T40.413A Poisoning by fentanyl or fentanyl analogs, assault, initial encounter
T40.414A Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter
T40.421A Poisoning by tramadol, accidental (unintentional), initial encounter
T40.422A Poisoning by tramadol, intentional self-harm, initial encounter
T40.423A Poisoning by tramadol, assault, initial encounter
T40.424A Poisoning by tramadol, undetermined, initial encounter
T40.491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter
T40.492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter
T40.493A Poisoning by other synthetic narcotics, assault, initial encounter
T40.494A Poisoning by other synthetic narcotics, undetermined, initial encounter
T40.5X1A Poisoning by cocaine, accidental (unintentional), initial encounter
T40.5X2A Poisoning by cocaine, intentional self-harm, initial encounter
T40.5X3A Poisoning by cocaine, assault, initial encounter
T40.5X4A Poisoning by cocaine, undetermined, initial encounter
T40.691A Poisoning by other narcotics, accidental (unintentional), initial encounter
T40.692A Poisoning by other narcotics, intentional self-harm, initial encounter
T40.693A Poisoning by other narcotics, assault, initial encounter
T40.694A Poisoning by other narcotics, undetermined, initial encounter
T40.711A Poisoning by cannabis, accidental (unintentional), initial encounter
T40.712A Poisoning by cannabis, intentional self-harm, initial encounter
T40.713A Poisoning by cannabis, assault, initial encounter
T40.714A Poisoning by cannabis, undetermined, initial encounter
T40.721A Poisoning by synthetic cannabinoids, accidental (unintentional), initial encounter
T40.722A Poisoning by synthetic cannabinoids, intentional self-harm, initial encounter
T40.723A Poisoning by synthetic cannabinoids, assault, initial encounter
T40.724A Poisoning by synthetic cannabinoids, undetermined, initial encounter
T40.8X1A Poisoning by lysergide [LSD], accidental (unintentional), initial encounter
T40.8X2A Poisoning by lysergide [LSD], intentional self-harm, initial encounter
T40.8X3A Poisoning by lysergide [LSD], assault, initial encounter
T40.8X4A Poisoning by lysergide [LSD], undetermined, initial encounter
T40.991A Poisoning by other psychodysleptics [hallucinogens], accidental (unintentional), initial encounter
T40.992A Poisoning by other psychodysleptics [hallucinogens], intentional self-harm, initial encounter
T40.993A Poisoning by other psychodysleptics [hallucinogens], assault, initial encounter
T40.994A Poisoning by other psychodysleptics [hallucinogens], undetermined, initial encounter
T42.0X1A Poisoning by hydantoin derivatives, accidental (unintentional), initial encounter
T42.0X2A Poisoning by hydantoin derivatives, intentional self-harm, initial encounter
T42.0X3A Poisoning by hydantoin derivatives, assault, initial encounter
T42.0X4A Poisoning by hydantoin derivatives, undetermined, initial encounter
T42.1X1A Poisoning by iminostilbenes, accidental (unintentional), initial encounter
T42.1X2A Poisoning by iminostilbenes, intentional self-harm, initial encounter
T42.1X3A Poisoning by iminostilbenes, assault, initial encounter
T42.1X4A Poisoning by iminostilbenes, undetermined, initial encounter
T42.2X1A Poisoning by succinimides and oxazolidinediones, accidental (unintentional), initial encounter
T42.2X2A Poisoning by succinimides and oxazolidinediones, intentional self-harm, initial encounter
T42.2X3A Poisoning by succinimides and oxazolidinediones, assault, initial encounter
T42.2X4A Poisoning by succinimides and oxazolidinediones, undetermined, initial encounter
T42.3X1A Poisoning by barbiturates, accidental (unintentional), initial encounter
T42.3X2A Poisoning by barbiturates, intentional self-harm, initial encounter
T42.3X3A Poisoning by barbiturates, assault, initial encounter
T42.3X4A Poisoning by barbiturates, undetermined, initial encounter
T42.4X1A Poisoning by benzodiazepines, accidental (unintentional), initial encounter
T42.4X2A Poisoning by benzodiazepines, intentional self-harm, initial encounter
T42.4X3A Poisoning by benzodiazepines, assault, initial encounter
T42.4X4A Poisoning by benzodiazepines, undetermined, initial encounter
T42.5X1A Poisoning by mixed antiepileptics, accidental (unintentional), initial encounter
T42.5X2A Poisoning by mixed antiepileptics, intentional self-harm, initial encounter
T42.5X3A Poisoning by mixed antiepileptics, assault, initial encounter
T42.5X4A Poisoning by mixed antiepileptics, undetermined, initial encounter
T42.6X1A Poisoning by other antiepileptic and sedative-hypnotic drugs, accidental (unintentional), initial encounter
T42.6X2A Poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm, initial encounter
T42.6X3A Poisoning by other antiepileptic and sedative-hypnotic drugs, assault, initial encounter
T42.6X4A Poisoning by other antiepileptic and sedative-hypnotic drugs, undetermined, initial encounter
T43.011A Poisoning by tricyclic antidepressants, accidental (unintentional), initial encounter
T43.012A Poisoning by tricyclic antidepressants, intentional self-harm, initial encounter
T43.013A Poisoning by tricyclic antidepressants, assault, initial encounter
T43.014A Poisoning by tricyclic antidepressants, undetermined, initial encounter
T43.021A Poisoning by tetracyclic antidepressants, accidental (unintentional), initial encounter
T43.022A Poisoning by tetracyclic antidepressants, intentional self-harm, initial encounter
T43.023A Poisoning by tetracyclic antidepressants, assault, initial encounter
T43.024A Poisoning by tetracyclic antidepressants, undetermined, initial encounter
T43.1X1A Poisoning by monoamine-oxidase-inhibitor antidepressants, accidental (unintentional), initial encounter
T43.1X2A Poisoning by monoamine-oxidase-inhibitor antidepressants, intentional self-harm, initial encounter
T43.1X3A Poisoning by monoamine-oxidase-inhibitor antidepressants, assault, initial encounter
T43.1X4A Poisoning by monoamine-oxidase-inhibitor antidepressants, undetermined, initial encounter
T43.211A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, accidental (unintentional), initial encounter
T43.212A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, intentional self-harm, initial encounter
T43.213A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, assault, initial encounter
T43.214A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, undetermined, initial encounter
T43.221A Poisoning by selective serotonin reuptake inhibitors, accidental (unintentional), initial encounter
T43.222A Poisoning by selective serotonin reuptake inhibitors, intentional self-harm, initial encounter
T43.223A Poisoning by selective serotonin reuptake inhibitors, assault, initial encounter
T43.224A Poisoning by selective serotonin reuptake inhibitors, undetermined, initial encounter
T43.291A Poisoning by other antidepressants, accidental (unintentional), initial encounter
T43.292A Poisoning by other antidepressants, intentional self-harm, initial encounter
T43.293A Poisoning by other antidepressants, assault, initial encounter
T43.294A Poisoning by other antidepressants, undetermined, initial encounter
T43.3X1A Poisoning by phenothiazine antipsychotics and neuroleptics, accidental (unintentional), initial encounter
T43.3X2A Poisoning by phenothiazine antipsychotics and neuroleptics, intentional self-harm, initial encounter
T43.3X3A Poisoning by phenothiazine antipsychotics and neuroleptics, assault, initial encounter
T43.3X4A Poisoning by phenothiazine antipsychotics and neuroleptics, undetermined, initial encounter
T43.4X1A Poisoning by butyrophenone and thiothixene neuroleptics, accidental (unintentional), initial encounter
T43.4X2A Poisoning by butyrophenone and thiothixene neuroleptics, intentional self-harm, initial encounter
T43.4X3A Poisoning by butyrophenone and thiothixene neuroleptics, assault, initial encounter
T43.4X4A Poisoning by butyrophenone and thiothixene neuroleptics, undetermined, initial encounter
T43.591A Poisoning by other antipsychotics and neuroleptics, accidental (unintentional), initial encounter
T43.592A Poisoning by other antipsychotics and neuroleptics, intentional self-harm, initial encounter
T43.593A Poisoning by other antipsychotics and neuroleptics, assault, initial encounter
T43.594A Poisoning by other antipsychotics and neuroleptics, undetermined, initial encounter
T43.621A Poisoning by amphetamines, accidental (unintentional), initial encounter
T43.622A Poisoning by amphetamines, intentional self-harm, initial encounter
T43.623A Poisoning by amphetamines, assault, initial encounter
T43.624A Poisoning by amphetamines, undetermined, initial encounter
T43.631A Poisoning by methylphenidate, accidental (unintentional), initial encounter
T43.632A Poisoning by methylphenidate, intentional self-harm, initial encounter
T43.633A Poisoning by methylphenidate, assault, initial encounter
T43.634A Poisoning by methylphenidate, undetermined, initial encounter
T43.641A Poisoning by ecstasy, accidental (unintentional), initial encounter
T43.642A Poisoning by ecstasy, intentional self-harm, initial encounter
T43.643A Poisoning by ecstasy, assault, initial encounter
T43.644A Poisoning by ecstasy, undetermined, initial encounter
T43.651A Poisoning by methamphetamines accidental (unintentional), initial encounter
T43.652A Poisoning by methamphetamines intentional self-harm, initial encounter
T43.653A Poisoning by methamphetamines, assault, initial encounter
T43.654A Poisoning by methamphetamines, undetermined, initial encounter
T43.691A Poisoning by other psychostimulants, accidental (unintentional), initial encounter
T43.692A Poisoning by other psychostimulants, intentional self-harm, initial encounter
T43.693A Poisoning by other psychostimulants, assault, initial encounter
T43.694A Poisoning by other psychostimulants, undetermined, initial encounter
T43.8X1A Poisoning by other psychotropic drugs, accidental (unintentional), initial encounter
T43.8X2A Poisoning by other psychotropic drugs, intentional self-harm, initial encounter
T43.8X3A Poisoning by other psychotropic drugs, assault, initial encounter
T43.8X4A Poisoning by other psychotropic drugs, undetermined, initial encounter
T44.0X1A Poisoning by anticholinesterase agents, accidental (unintentional), initial encounter
T44.0X2A Poisoning by anticholinesterase agents, intentional self-harm, initial encounter
T44.0X3A Poisoning by anticholinesterase agents, assault, initial encounter
T44.0X4A Poisoning by anticholinesterase agents, undetermined, initial encounter
Z51.81* Encounter for therapeutic drug level monitoring
Z71.51* Drug abuse counseling and surveillance of drug abuser
Z79.891* Long term (current) use of opiate analgesic
Z79.899* Other long term (current) drug therapy
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual diagnosis requirement: ICD-10 codes Z51.81, Z79.891, and Z79.899 must be reported with ICD-10 code G89.21, G89.22, G89.28, G89.29, or G89.4, OR an ICD-10 code from the M02 – M99 range for pain management patients.

*Dual diagnosis requirement: ICD-10 code Z71.51 must be reported with an ICD-10 code from the F11 – F16 or F19 range for patients in rehabilitation for drug abuse (the ICD-10 codes in the above table for F11 – F16 and F19 are standalone codes).

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
CodeDescription
XX000 Not Applicable

ICD-10-PCS Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
999x Not Applicable

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

CodeDescription
99999 Not Applicable

Other Coding Information

N/A

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Updated On Effective Dates Status
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Keywords

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