Medicare Compliance & Reimbursement

Urine cultures are commonplace in many urology offices, but with multiple codes to choose from, the coding can be anything but routine. Learn how to dig into the details to ensure you choose the right code every time and avoid miscoding and lost reimbursement.

Physicians most often use bacterial urine cultures on urine specimens to establish the probability of a urinary tract infection (UTI). They can also perform the cultures to diagnose urine-related conditions as part of an evaluation and management service, says CMS' National Coverage Determination (NCD) on urine cultures.

For these types of basic urine cultures, you need to look at 87086 (Culture, bacterial; quantitative colony count, urine) and 87088 (... with isolation and presumptive identification of each isolate, urine).

When your physician orders a urine culture for the initial identification of a bacterial organism in a urine sample, you should turn to 87086. Use 87086 when the physician performs a urine culture colony count to determine the approximate number of bacteria present per milliliter of urine.

Urine culture code 87088 describes the use of a commercial kit that uses manufacturer-defined media for isolation, presumptive identification and quantification of morphotypes present, according to the NCD.

"In the past, you were unable to report 87086 and 87088 for the same encounter," says Chandra L. Hines, business office manager for NC Urological Associates Inc. in Raleigh, NC. Now you can report 87086 and 87088 during the same encounter.

Reasoning: Most lab culture codes include both the isolation and presumptive organism identification. Although urine culture code 87086 is unique, another code is also available to report presumptive identification (87081, Culture, presumptive, pathogenic organisms...) in addition to 87086 for the isolation.

You should report 87088 only after you've already reported 87086 and the physician has positively identified significant bacterial growth in the urine.

"Once a culture is planted, it takes two days to get results. After the [positive] result is recorded in EMR, I then print out a report and report 87088 and 87086 with modifier 59 together. We do not report separately," says Nancy Giffin, MA, CPC, billing manager for five physicians at the Swedish Urology Group in Seattle. To bill both codes, you must have documentation of the presumptive identification of an organism.

You don't need any modifiers to receive payment for both codes -- and reporting 87088 will increase your reimbursement because it pays about the same as 87086.

Example: A physician sees a patient with burning on urination, frequency, and urgency of urination. A urinalysis reveals many white blood cells and microscopic hematuria. The doctor suspects a UTI and orders a urine culture and quantitative colony count (87086).

This culture indicates a large number of bacteria (over 100,000 organisms per ml). Having confirmed a significant UTI and wishing to know the organism(s) involved in causing the infection, the physician then orders an identification of the bacteria (87088).

If a urine culture is positive for bacterial growth, your physician may perform one of two additional urine tests to determine the antibiotic sensitivity of the infecting micro-organisms: 87184 (Susceptibility studies, antimicrobial agent; disk method, per plate [12 or fewer agents]) or 87186 (... microdilution or agar dilution [minimum inhibitory concentration (MIC) or breakpoint], each multi-antimicrobial, per plate). These urine studies represent two types of susceptibility or sensitivity studies available to the physician.

In 2004, Medicare published the most recent NCD on urine cultures. That regulation specifies six indications for urine cultures/studies. To support medical necessity, your physician's documentation should show one of these indications. The criteria Medicare lists in the NCD include but are not limited to:

• The patient has abnormal urinalysis results that suggest a UTI, such as hematuria or pyuria.

• The patient has clinical symptoms, such as urinary frequency (788.41) and burning (788.1, Dysuria), which indicate a possible acute lower or upper urinary tract infection.

• The patient presents with a fever of unknown origin (780.6) or suspected urosepsis (599.0).

• The physician orders the urine culture as a means of detecting occult infection in a renal transplant recipient who is on immunosuppressive therapy.