Oncology & Hematology Coding Alert

Be sure you're in the loop when the automated machine needs repairs.

Proper documentation of urinalysis (UA) codes 81000-81003 begins with a signed order and isn't complete until you have proof of service rendered. Help your practice meet medical record requirements for these codes:

• 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.

Create a Plan to Ensure Written Order

Medicare has specific requirements for ordering diagnostic tests. But in an office setting, the physician and nurse are talking constantly, so overlooking the written order is an easy mistake to make, warns Joan Gilhooly, CPC, PCS, CHCC, president of Ohio-based Medical Business Resources.

If you have an electronic medical record (EMR) with a designated spot for orders, make it standard practice to include orders there. If you don't use an EMR, work with providers to ensure the medical record contains a written order. Keep in mind that although you'll find Medicare manual entries that state "no signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule ...," the manuals go on to say "there must be medical documentation (e.g., a progress note) by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature." See CMS Program Integrity Manual (100-08), Chapter 3, Section 3.3.2.4 (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c03.pdf) and Medicare Benefit Policy Manual (100-02), Chapter 15, Section 80.6.1 (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf).

Microscopy must: To support using the microscopy codes (81000, 81001), the order must specify microscopy. Otherwise, medical review auditors will reduce the service to a "without microscopy" code. For example, a WPS Medicare document states, "If the intention is to order a urinalysis with microscopy, it must be clearly noted on the order or payment will be reduced" (www.wpsmedicare.com/j5macpartb/training/on_demand/_files/diag-handout-3.pdf). This may seem like a minor issue as the difference in reimbursement is less than one dollar, but the volume of these services in most practices can be substantial when added up over any length of time.

Plan Ahead for When Machine Breaks

The UA order doesn't need to specify whether the test should be automated (because it is a matter of method), but you will need to know the method to choose the proper code.

Generally speaking, the automated (81001, 81003) method results in a print-out from the machine used. In contrast, the non-automated (81000, 81002) method results in documentation by the tester, says Gilhooly.

Problem solver: If the staff performs an automated test but the machine's printer is broken, the documentation will be by the tester rather than being in the usual printout format. In those cases, the tester should document the test was automated to support use of an automated code, Gilhooly says.

Practices that use the automated method also need to prepare for when machine troubles require the staff to use a non-automated method. Because the practice's standard test is automated, the superbill may include only automated test codes. As a result, staff may circle an automated code for a non-automated test, leading to incorrect coding, says Gilhooly. Prevent this problem by alerting staff to the issue and including both automated and non-automated codes on the superbill. Or if you use an electronic or facility system, verify the necessary information is in the electronic charge dictionary with proper choices or in the facility charge description master (CDM or EAP) files.

Audit-Proof Non-Automated Documentation

If your practice uses non-automated testing, one way to simplify documentation is to have a urinalysis form showing each component measured by the test you use. For example, if the dip stick supply you use tests for all 10 elements in the codes, then list each of the 10 elements and allow space after each for the tester to fill in the results, Gilhooly suggests.

You also will want to perform a final check before billing to ensure your documentation ducks are in a row.

Example: A sample case could involve a practice using a lab sheet that records performance of 81000 (dip and microscopy, non-automated) for a patient with mixed incontinence (788.33, Mixed incontinence [male] [female]), says Alice Kater, CPC, PCS, coder for a South Bend, Ind., practice. The lab sheet is included as part of the medical record, which additionally includes in the chart: "Urinalysis shows no protein, no glucose, no heme, pH5. Micro exam shows rare WBC, otherwise negative. Urine is unremarkable." Before posting the charge, the practice checks the lab sheet against the encounter to ensure the team (1) performed a UA, (2) billed it, and (3) documented it in the EMR, Kater says.

Also see: "81002 or 81003? Here's How to Pinpoint the Proper Code" in Oncology & Hematology Coding Alert, vol. 14, no. 7, provides more information on proper urinalysis coding.