Though your lab gets a number of urinalysis (UA) tests every day, that doesn’t make coding these straight-forward coding situations any easy. With multiple CPT® codes for urine constituents, follow our experts’ guidelines to increase you UA coding accuracy so you can get the pay you deserve.
Tip 1: Distinguish Codes by Constituents
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- 81000—Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy
- 81001—… automated, with microscopy
- 81002—… non-automated, without microscopy
- 81003—…automated, without microscopy
- 81005—Urinalysis; qualitative or semiquantitative, except immunoassays
- 81007—… bacteriuria screen, except by culture or dipstick
- 81015—… microscopic only.
10 constituents: Codes 81000–81003 apply to testing “any number” of the listed constituents, so whether you test for one of the items or all of them, you should report a single unit of the appropriate code, says Joan Gilhooly, CPC, PCS, CHCC, president of Ohio-based Medical Business Resources. For instance, a single unit of 81002 would apply to either a non-automated tablet test without microscopy for ketones or a non-automated chem-strip test without microscopy for all 10 elements.
Other than 10 constituents: For UA tests that don’t involve the 10 constituents described in 81000-81003, you should choose the appropriate code from the range 81005-81015.
For example: “If a physician orders a test for other urine constituents such as melanin or reducing sugars (other than glucose), report 81005 (except immunoassays),” says William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.
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