Appendix IV: Billing UDT

Implementing UDT requires addressing numerous facets, and sustainability of the program and compensation for physician time are important for any program’s success. This section covers the billing of UDT…

There is a wide range of variability when billing urine drug testing that depends on numerous factors. This section is written for family physicians in the province of Ontario, however note that there are numerous different payment models and so there is no single approach. Also note that we are in an uncommon payment model called a Rural Northern Physician Group Agreement (RNPGA) where our UDT is considered “in-the-basket” and we receive 5% shadow-billing for what we bill. This has naturally led to us not being experts in the practical application of billing UDT ourselves.

Nevertheless, we have done the homework and at least laid out a review of the OHIP Schedule of Benefits that summarizes the important billing codes for UDT. Highlighted are points 4-8 as they are the most relevant when billing UDT for CNCP. Note that some of the billing codes referenced below – K682 and K683 (OAT), and K623 and K624 (Form 1 and Form 3) – would not be applicable to your CNCP patients.

B. Point of care drug testing	Fee
G041 Target drug testing, urine, qualitative or quantitative	per test 3.70
G042 Target drug testing, urine, qualitative or quantitative [Commentary: G041 and G042 are tests for a specific drug of abuse.]	per test 2.50
G040 Drugs of abuse screen, urine, must include testing for at least four drugs of abuse	per test 15.00
G043 Drugs of abuse screen, urine, must include testing for at least four drugs of abuse [Commentary: Drugs of abuse may include any of the following: alcohol, methadone, methadone metabolite, morphine, a synthetic or semisynthetic opiate, cocaine, benzodiazepines, amphetamines, methamphetamines, cannabinoids, barbiturates or any other drug of abuse.]	per test 7.50
G039 Creatinine	1.03

Payment Rules:
For the purposes of opioid agonist maintenance treatment, G040, G042, G041 and G043 are only eligible for payment to a physician who has an active general exemption for methadone maintenance treatment or chronic pain treatment with methadone pursuant to Section 56 of the Controlled Drugs and Substances Act 1996. G040 and G041 are limited to a maximum of five (5) services per patient (any combination) per month to any physician when K682 or K683 is payable. G042 and G043 are limited to a maximum of four (4) services per patient (any combination) per month to any physician when K682 or K683 is payable. Any combination of G040, G041, G042 and G043 is limited to a maximum of three (3) services per patient per month for management of a patient with chronic pain, an addiction, or receiving opioid agonist treatment program where K682 or K683 is not payable in the month for the same patient to any physician. G040, G041, G042 and G043 are not eligible for payment unless K623 or K624 or a consultation, assessment or time– based service involving a direct physical encounter with the patient is payable in the same month to the same physician rendering the G040, G041, G042 or G043 service. G039 is limited to a maximum of two (2) tests per patient per week, any physician. G039 is only eligible for payment when rendered to rule out urine tampering. Only one of G040, G041, G042 or G043 is eligible for payment per urine sample.

Payment Rules:

For the purposes of opioid agonist maintenance treatment, G040, G042, G041 and G043 are only eligible for payment to a physician who has an active general exemption for methadone maintenance treatment or chronic pain treatment with methadone pursuant to Section 56 of the Controlled Drugs and Substances Act 1996.
G040 and G041 are limited to a maximum of five (5) services per patient (any combination) per month to any physician when K682 or K683 is payable.
G042 and G043 are limited to a maximum of four (4) services per patient (any combination) per month to any physician when K682 or K683 is payable.
Any combination of G040, G041, G042 and G043 is limited to a maximum of three (3) services per patient per month for management of a patient with chronic pain, an addiction, or receiving opioid agonist treatment program where K682 or K683 is not payable in the month for the same patient to any physician.
G040, G041, G042 and G043 are not eligible for payment unless K623 or K624 or a consultation, assessment or time– based service involving a direct physical encounter with the patient is payable in the same month to the same physician rendering the G040, G041, G042 or G043 service.
G039 is limited to a maximum of two (2) tests per patient per week, any physician.
G039 is only eligible for payment when rendered to rule out urine tampering.
Only one of G040, G041, G042 or G043 is eligible for payment per urine sample.

Adapted from OHIP Schedule of Benefits¹

So practically what this means is that if you do an IA UDT in the office with at least 4 panels, then you would bill a G040 ($15). You must have assessed the patient in that month to be eligible. Maximum of 3 in a given month (for chronic pain patients, this upper limit is only relevant for those that are in your “structured” risk stream as no other patients would be doing even close to this frequency). If you also do anti-tampering with creatinine and/or pH/specific gravity/oxidants, etc. then you would bill a G039 as well.

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