ED Coding and Reimbursement Alert

Question: When we code a urinalysis (UA), the lab template says, "culture if indicated." We report the diagnosis the doctor gave for the UA at the start. However, the lab manager wants us to code the reason for the culture based on the UA findings, because the claims often get denied.
 
There is a code for abnormal UA findings, but I have been trying to explain to her that we cannot code off of the UA results without the physician's interpretation of them. She argued that there is a criterion in place as to when to perform a culture, and she was wondering if we could code the abnormal findings - because when the lab does a culture, it is due to abnormal findings on the UA. How should I resolve this?

South Dakota Subscriber

Answer: The criterion your lab manager is referring to is called reflex testing, which means the lab sets standards as to when additional testing can automatically be done without the need for an additional order from the physician. For these tests, you still need the emergency department physician to state that there is an abnormal test result (the 791.x series) in order to report the culture codes, because a nonphysician cannot assign a diagnosis to a service based on the results of a test that has not been interpreted by a physician.
 
Tip: Don't take the lab manager's word for it - check with the payer (or tell her to check) to see exactly why the claims are receiving denials. You may find that it has nothing to do with the abnormal-findings codes.