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I bill for a pain specialist and we are getting denials for 80305 from medicare for not covered when considered routine. We are using the primary dx and also have used other ICD 10 and are still getting denied. Has anyone been able to receive reimbursement for this code?
Have you checked your LCD to see if its a covered diagnosis?

For instance some excerpts from Novitas Solutions, Inc.

Controlled Substance Monitoring and Drugs of Abuse Testing (L35006)
Group A – Symptomatic patients, multiple drug ingestion or patients with unreliable history.

A patient who presents in a variety of medical settings with signs or symptoms of substance use toxicity will be treated presumptively to stabilize the patient while awaiting rapid, then definitive testing to determine the cause(s) of the presentation.

The need for definitive UDT is based upon rapid test findings, responses to medical interventions, and treatment plan.

A presumptive UDT should be performed as part of the evaluation and management of a patient who presents in an urgent care setting with any one of the following:
· Coma
· Altered mental status in the absence of a clinically defined toxic syndrome or toxidrome
· Severe or unexplained cardiovascular instability (cardiotoxicity)
· Unexplained metabolic or respiratory acidosis in the absence of a clinically defined toxic syndrome or toxidrome
· Seizures with an undetermined history
· To provide antagonist to specific drug

Group B - Diagnosis and treatment for substance abuse or dependence.

A patient in active treatment for substance use disorder (SUD) or monitoring across different phases of recovery may undergo medical management for a variety of medical conditions.

Group C - Treatment for patients on chronic opioid therapy (COT).

A physician who is writing prescriptions for medications to treat chronic pain can manage a patient better if the physician knows whether the patient is consuming another medication or substance, which could suggest the possibility of SUD or lead to drug-drug interactions. Additionally, UDT may help the physician monitor for medication adherence, efficacy, side effects, and patient safety in general.
I bill Medicare 80305 with QW modifier and diagnosis code Z79.899 and we get paid with no issues and I also bill for pain management provider. Please note Medicare will only allow 12 in a calendar year.