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Presumptive vs Confirmatory Drug Testing – Which Is Appropriate?

A prevalent practice among prescribing doctors is to automatically send a urine sample out for confirmatory (quantitative) drug testing.  Average billing for the confirmatory testing is around $2000 but if they test for an extensive number of drugs, it can be as high as $4000.  This is different than qualitative testing, also known as point of contact or presumptive testing, which identifies drug classifications, such as opiates, muscle relaxants, anti-depressants, etc., but not specific drugs, and is a lot less expensive.  Many physicians perform the qualitative testing in their own offices, then send the sample to an outside lab to perform the quantitative confirmatory testing for specific drugs.  There are some practices that send urine samples out to a lab for qualitative (presumptive) testing also, because they don’t have the capability to perform that testing onsite.  CPT codes allow us to recognize whether they are obtaining presumptive or confirmatory testing.

A recent trend we are beginning to see is that doctors, particularly those in the larger pain management practices, are obtaining the testing equipment to perform the confirmatory testing in their own office.  The problems with that are 1) the more drugs they test for, the more they can charge which potentially leads to excessive testing on multiple patients; and 2) ODG recommendations are that confirmatory testing only be done if the presumptive qualitative testing shows inconsistencies, other red flags,  or the claimant is considered high risk for abuse as evidenced by either previous irregularities with testing or using objective testing tools to show the patient is predisposed towards high risk behaviors.  

We monitor  all requests for UDS very closely, both by report and CPT codes, to watch for confirmatory testing done by rote as a business practice which is not according to ODG, versus medical necessity which is compliant with treatment guidelines.  Many times, the adjusters don’t realize ODG has criteria for the use of confirmatory testing or don’t know quantitative testing is performed until they get the bill.  Those tests would, therefore, be subject to retrospective review.  The doctor would be responsible for appropriate documentation to support medical necessity.  It usually only takes one or two denials of the expensive quantitative drug test bills for the treating doctor to rethink the wisdom of automatic confirmatory testing.  Outside labs are not pleased to have their bills delayed for retrospective review or denied because the confirmatory quantitative testing is not compliant with ODG criteria.   

Those labs have rendered their services at the request of the physician, and most likley are not familiar with ODG recommendations and criteria for confirmatory drug testing.