Pathology/Lab Coding Alert

Question: Our lab received two urine specimen tubes for complete urinalysis with reflex to culture. The findings from the complete urinalysis showed elevated white blood cells, so the lab completed a culture on the second specimen but did not isolate an organism. How should we code this (procedure and diagnosis)?

Iowa Subscriber

Answer: Report the urinalysis as 81001 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy). For the urine culture, you should report 87086 (Culture, bacterial; quantitative colony count, urine), even though the lab doesn’t isolate or identify an organism.

Here’s why: Urine specimens are often sterile or nearly so and therefore won’t show colony growth. CPT^® provides two codes for urine culture: 87086 and 87088 (Culture, bacterial; with isolation and presumptive identification of each isolate, urine). If the culture results in identifying an isolate, you would report both codes, but when the urine culture is negative, you should report only 87086.

Diagnosis: The ordering physician may have assigned a diagnosis based on the patient’s symptoms, and the clinical lab can use that as the diagnosis. However, the correct ICD-10-CM code for elevated white blood cells (WBC) is R82.81 (Pyuria), and you may report that since it’s the only finding.

UTI: If the culture had resulted in an isolate and the lab identified an organism, the clinician might then assign a code such as N39.0 (Urinary tract infection, site not specified). A note under that code instructs the coder to “use additional code (B95-B97), to identify infectious agent,” so the clinician can assign the correct code organism code if the lab has provided the information about the culture identification.