Overview of MassHealth Drug Tests and Screens

A brief look at MassHealth's spending and regulations related to drug tests and screens.

Overview

Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services to approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities annually. In fiscal year 2016, MassHealth paid healthcare providers more than $14.8 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.

According to Section 401 of Title 130 of the Code of Massachusetts Regulations (CMR), MassHealth covers medically necessary laboratory services, including drug tests and screens, provided to its members. The following table shows the numbers of claims and members served, as well as the amounts paid for drug tests and screens, from March 1, 2013 through June 30, 2017.

Paid Claims for Drug Tests and Screens

Year	Amount Paid	Number of Claims	Members Served
2013	$   9,658,373	578,219	91,284
2014	8,286,150	550,125	108,925
2015	7,414,465	464,665	92,278
2016	9,070,094	390,514	96,221
2017	4,839,077	191,874	58,457
Total	$ 39,268,159	2,175,397

Billing for Drug Tests and Screens

When billing for drug tests and screens, MassHealth requires providers to bill based on whether the service provided is a drug screen, a drug test, or a combination of both when allowed (e.g., when they are performed on different dates of service). MassHealth also refers to drug screens as “qualitative drug screens” or “presumptive drug screens”; their results produce a positive or negative result for each drug class tested.¹ Providers typically use such screens when treating members for substance use disorders (SUDs), since they only need to determine whether any illicit substance is present in a member’s sample.

In contrast, a drug test is used to identify the quantity of a substance in a specific sample. MassHealth also refers to drug tests as “quantitative drug tests” or “definitive drug tests.” They are more expensive than drug screens and are used by providers for treating members in emergency settings and for medication management.

Sometimes providers use a combination of drug screens and drug tests to treat members. For example, in treating a member for SUDs, a drug screen may produce a positive result for the opioid drug class. After reviewing the results, the provider may want to confirm these results by ordering a quantitative drug test for specific substances in that drug class, e.g., oxycodone, fentanyl, heroin, or morphine. MassHealth allows drug tests to be used in this manner, but it cautions providers against routinely using drug tests rather than the less expensive drug screens.

Conditions and Limitations in Payment for Drug Tests

In accordance with 130 CMR 401.416(A), MassHealth pays laboratories for drug tests and drug screens as long as the laboratory has received “a written request to perform that specific service from an authorized prescriber who is treating the member and will use the tests for the purpose of diagnosis, treatment, or any otherwise medically necessary reason.”

MassHealth instructs laboratories to use specific procedure codes for each qualitative drug screen and quantitative drug test performed on its members. Additionally, MassHealth does not allow providers to bill for quantitative drug tests performed on a member on the same day as a qualitative drug screen. This practice is called unbundling and is discussed in further detail below.

Unbundling of Drug Tests

Beginning in January 2013, in response to findings from a previous Office of the State Auditor audit, MassHealth developed and implemented a system edit to prevent and deny payment for certain drug test procedure codes when billed for the same member on the same day. MassHealth intended this system edit to prevent laboratories from unbundling certain quantitative drug test procedure codes when also billing for qualitative drug screens provided to a MassHealth member on the same day. The Centers for Medicare and Medicaid Services define and describe two types of unbundling practices in Version 12.3 of the National Correct Coding Initiative Policy Manual for Medicare Services:

Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code.

Two types of practices lead to unbundling. The first is unintentional and results from a misunderstanding of coding. The second is intentional and is used by providers to manipulate coding in order to maximize payment.

1. A drug class is a group of medications that have the same or similar chemical structures. For example, the opioid drug class includes oxycodone, fentanyl, naloxone, morphine, heroin, and hydrocodone.

Date published:	April 19, 2018