Pathology/Lab Coding Alert

Question: Our lab performed a macroscopic urine test, but due to color interference, we could report only color and clarity as results. We proceeded to perform the microscopic exam on the specimen. Can we report a complete urinalysis code?

South Dakota Subscriber

Answer: No, you should not report a complete urinalysis using a code such as 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) or 81001 (... automated, with microscopy).

Instead, you should bill only for the microscopic exam using 81015 (Urinalysis; microscopic only).

Here's why: Because color and clarity are observations, not any of the listed components of a urinalysis (81000 or 81001), you can't use those codes. The definition says "any number of these constituents" but the lab was unable to identify any of the constituents. Because the lab successfully performs and gets results only from the microscopic exam, that is all you should report.