Summary
New Jersey Medicaid/NJ FamilyCare has restructured drug testing billing procedures, terminating multiple presumptive drug screening codes (G0434, 80102, 80104) while re-approving G0481 and introducing G0481HF for substance use programs. As of July 1, 2026, all substance use testing will be reimbursed by managed care plans rather than fee-for-service Medicaid. Billing teams must immediately halt use of terminated codes, implement strict utilization limits (presumptive: 1 per day/10 per 28 days; definitive: 2 per 28 days), and ensure clinical justification for definitive testing is documented.
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What to do
Action · 10 steps
01IMMEDIATE ACTION REQUIRED - By July 1, 2026.
02Billing team must update billing system to TERMINATE all claims for codes G0434, G0434 HF, G0434 QW, G0482, G0483, 80102, 80102 HF, 80104, 80104 HF, and 80104 QW - these will be denied if submitted.
03Re-activate G0481 billing for any authorized provider; activate G0481HF ONLY for SUD Outpatient Treatment Providers.
04Implement system edits to enforce utilization limits: Presumptive drug tests (80305, 80306, 80307 and HF variants) = maximum 1 per date of service AND 10 per rolling 28 days; Definitive drug tests (G0480, G0481 and HF variants) = maximum 2 per rolling 28 days.
05Configure system to deny definitive drug test claims (G0480, G0481) unless a paid presumptive test claim exists for same date or within 7 days prior.
06Update provider/lab education materials to restrict definitive testing only when: patient disputes result, specific substance detection needed, substance not identified by presumptive methods, or results inform major clinical decisions.
07Deny payment for CPT codes 84311, 83986, 82570, 83789, 84315 when billed same date as presumptive/definitive drug tests.
08Implement post-payment audit protocols to flag inappropriate billing.
09Redirect all managed care members' drug testing claims to their managed care plan effective July 1, 2026; continue FFS submissions through Gainwell only for non-managed care members.
10Educate providers that 'blanket orders' (identical tests for all patients) are not covered; only 'standing orders' based on evidence protocols, patient-specific, updated annually, and effective no longer than 12 months are allowed.
If missed: Failure to comply will result in claim denials and potential fraud audits.
Codes mentioned
G0434G0480G0481G0482G048380102801048030580306803078431183986825708378984315
Original notice
Newsletter Vol. 36, No.08
njmmis.com · Always check the source before changing claims.
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