CPT Codes Guide - Healthcare

CPT code for Urinalysis

In this article will learn about CPT code for Urinalysis and its guidelines along with examples.

Urinalysis (UA) is analysis or screening of urine sample by physical, chemical or microscopical means in order to detect any disease such as UTI, diabetes, kidney disorders, liver problems etc and also to determine pregnancy. It can even detect any presence of drugs in urine.

Physician orders for urinalysis when a patient shows symptoms such as blood in urine, low back pain, abdominal pain, frequent urination, painful urination or cloudy urine.

Sample collection and Steps in Urinalysis:

Urine sample is collected directly into a sample cup and analysis is done in laboratory by lab technician. Below are the steps followed in performing Urinalysis.

Visual Exam: – Direct eye examination is done to identify the colour and clarity (dark, cloudy, bloody, foamy) of urine.

Dipstick Test: — A chemical coated plastic strip is dipped into urine. The chemicals on strip will react to urine and show colour change as per acidity or pH. This helps to detect kidney or liver problems, glucose, blood bilirubin, nitrate and leukocyte esterace.

Microscopic Exam: — Urine is examined under a microscope to detect any skin cells, bacteria, RBC, WBC, crystals, bacteria or parasites.

There is another urine test called Urine culture (culturing of bacteria found in urine) which is used to find out any infection.

CPT Code for Urinalysis and Guidelines:

CPT Codes for Urinalysis is found in section “Pathology and Laboratory” of CPT book, CPT code for Urinalysis ranges from 80047 – 89398

  • Do not report CPT 81005 if there is immunoassay or biochemical test is used.
  • Do not report CPT 81007 if the test is done using culture or dipstick method.
  • Check for Local Coverage Determination (LCD) to confirm the medical necessity when coding each CPT. Incorrect ICD coded along with CPT will lead to denial of the claim or CPT.
  • Check National Correct Coding Initiative (CCI) edits when coding multiple CPTs in one DOS (date of service) to avoid denial.
  • Always remember to look for the correct method of the test to assign correct Code.
  • In automated test, an equipment or machine is used to read the dipstick colour change and determine the interpretation. The dipstick results are read manually in non-automated test.
  • Reflexive Test – Sometimes one lab test is done after another one if the result indicates to do a further study. Both the tests are coded at that time following CCI edits.

For example, urine culture is done after doing urinalysis automated without microscopy if result is positive for nitrites or yeast. Code both 81003 (urinalysis) and 87086 (culture) at that time.

  • Routine urinalysis is coded to CPT 81002
CPT code for Urinalysis CPT Code for Urinalysis – Description
81000 Urinalysis by dipstick or tablet reagent , non-automated, with microscopy
81001 Urinalysis by dipstick or tablet reagent , automated, with microscopy
81002 Urinalysis by dipstick or tablet reagent , non-automated, without microscopy
81003 Urinalysis by dipstick or tablet reagent , automated, without microscopy
81005 Qualitative or semiquantitative urinalysis
81007 Bacteriuria screen using commercial kit
81015 Urinalysis done only by microscopic examination
81020 Glass Test (sample labeled as glass 1,2 and at times 3 are all from one patient and examined microscopically)
81025 Urine pregnancy Test
81050 Volume measurement of urine during a timed collection
81099 Unlisted urinalysis, use this when there is no specific code for the particular type of analysis done

Guidelines to use Modifier with CPT code for Urinalysis:

  • Below are the list of modifiers that can be used with CPT code of Urinalysis.

22, 52, 59, 90, 91, 99, AR, CR, ET, GA, GC, GR, GY, GZ, KX, Q0, Q5, Q6, QJ, QP, XE, XP, XS, XU

  • There should be appropriate modifier used with E&M if required when lab tests are coded along with E&M codes (eg: 99284, 99213)
  • Refer policies of specific CPTs which are not reimbursable along with E&M though there is 25 modifier and 59 mod with CPT.
  • Check the latest CLIA (Clinical Laboratory Improvement Amendments) waived list of CPTs for using QW modifier. CPT 81003 and CPT 81007 are to be reported with QW modifier as per the latest list. Modifier QW should be reported as a primary modifier along with theses CPTs.

Few examples given here on coding Urinalysis CPT codes.

CPT code for Urinalysis Example 1:

28 year old Eliana is an established patient, here today with fever, abdominal pain and painful urination from past 2 days. Her vitals were noted and fever showed 102 degree. Physical exam indicates lower abdominal pain. All other exams are normal. Physicain ordered urinalysis. A Bacteuria screening test was done using commercial kit. Test results does not show anything abnormal.

Coding for this scenario would be:

99213 – R50.9 (Fever), R10.30 (Lower abdominal pain)

81007 – QW – R30.0 (Dysuria)

Note: QW modifier is given as it is CLIA waived test. Dx R30.0 is used as per LCD policy. Laboratory CPT should be coded as per client instructions when used along with E&M.

CPT code for Urinalysis Example 2:

A pathology coder received a lab report of Urinalysis.

Indication – frequency of urination.

Test performed – Automated with microscopy.

Interpretation – UTI

Coding for this scenario would be:

81001 – N39.0 (UTI)

Note: Do not code indication when there is definitive interpretation.