Internal Medicine Coding Alert

Question: I am new to internal medicine coding and have a question or two about urinalyses. What CPT codes will I use for these services, and can I ever report an E/M service along with a urinalysis code?

Kentucky Subscriber

Answer: Your internist may perform a urinalysis or urine culture, either as a diagnostic procedure or as part of a routine exam. CPT includes several codes for these services. You should choose from one of these codes, based on the internist's notes:

• 81000 -- Urinalysis, by dipstick 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 semiquanti- tative, except immunoassays

• 81007 -- ... bacteriuria screen, except by culture or dipstick

• 81015 -- ... microscopic only

• 81020 -- ... two or three glass test

• 81050 -- Volume measurement for timed collection, each

• 81099 -- Unlisted urinalysis procedure

• 87086 -- Culture, bacterial; quantitative colony count, urine

• 87088 -- ... with isolation and presumptive identifi- cation of each isolate, urine.

Keep in mind: Do not fragment the internist's urinalysis service and report it with multiple codes if a single code describes the service. For example, your in-office lab carries out a non-automated dipstick urinalysis with microscopic evaluation.

Correct coding: Report one unit of 81000.

Incorrect coding: Report both 81002 and 81015.

E/M question: The internist (or nurse) will need to conduct more than a urinalysis to bill an extra E/M service for the encounter. To report an E/M with urinalysis, you must document a chief complaint, take a history, perform an examination and have an assessment plan -- even if you are only billing a nurse's visit (99211, Office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent supervising these services).

The documentation must support the medical necessity for both the office visit and need for urinalysis.