Understand urine drug screen (UDS) medical coding, clinical documentation requirements, and result interpretation. Find information on UDS CPT codes, common drug test panels, and best practices for healthcare professionals documenting UDS results in patient charts. Learn about urine drug testing guidelines, cutoff levels, and the role of laboratory testing in substance abuse diagnosis and treatment.
Also known as
Other specified abnormal findings
Abnormal findings in urine drug screen results.
Poisoning by drugs, medicinal and biological substances
Adverse effects from drug use, detectable in urine.
Encounter for drug level monitoring
Patient encounter specifically for urine drug screen monitoring.
Encounter for screening for drug use
Routine or mandated drug screening via urine testing.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the UDS for routine/pre-employment screening?
Yes
Do not report a code. UDS is for administrative purposes.
No
Is the UDS for monitoring medication compliance?
When to use each related code
| Description |
|---|
| Urine drug screen |
| Qualitative drug test |
| Quantitative drug test |
Coding based on presumptive drug class (e.g., opiate vs. specific opioid) prior to confirmatory testing creates coding and billing inaccuracies.
Incorrect coding distinction between qualitative (presence/absence) and quantitative (specific amount) drug screen results leads to compliance issues.
Lack of documented medical necessity for the urine drug screen may trigger denials and raise audit red flags for healthcare compliance.
Urine drug screen (UDS) ordered due to concerns regarding substance use, patient reported (opioid dependence, prescription drug misuse, illicit drug use), or for monitoring purposes (medication compliance, pain management, addiction treatment). Patient provided a urine sample, which was analyzed via immunoassay with confirmatory testing if indicated. Results reviewed and interpreted within the context of the patient's clinical presentation, including history, physical examination, and other relevant laboratory data. UDS results positive for (specific drug or drug class detected e.g., benzodiazepines, amphetamines, opiates, cocaine, marijuana THC) at a concentration of (numerical value with units). Results negative for (specific drug or drug class not detected). The clinical significance of these findings was discussed with the patient, addressing potential drug interactions, overdose risk, and treatment options. Recommendations may include counseling, referral to addiction specialist, medication adjustment, or further diagnostic evaluation. Differential diagnosis includes false positive or negative results, medication cross-reactivity, and laboratory error. Plan to monitor patient's progress and continue to assess for substance use disorders. ICD-10 code (appropriate code based on specific substance and context, e.g., F11.10 Opioid dependence, unspecified) and CPT code (appropriate code for the UDS performed, e.g., 80307 Drug screen, qualitative; multiple drug classes by high complexity test method e.g., chromatographic and immunoassay methods) assigned. Documentation reviewed and finalized.