Pathology/Lab Coding Alert

Question: We know that Medicare is reviewing urine reflex cultures, and we're wondering if we can reflex to urine culture due to findings indicative of UTI: positive esterase, nitrite and WBC?

Minnesota Subscriber

Answer: As you mentioned, reflexing to urine culture based on urinalysis findings is something Medicare is watching closely. That's why you need to ensure that the physician actually "orders" the reflex test based on specific findings.

How you do it: You might establish laboratory protocols for results that reflex to the urine culture (87086, Culture, bacterial; quantitative colony count, urine) -- in your case, positive esterase, nitrite and white blood cells (WBC) found on initial urinalysis that the physician orders (such 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). Then, you need to ensure that the physician order includes the request for the reflex testing based on those findings.

As Medicare's laboratory national coverage determination (NCD) for urine culture states, "The physician's request may be through clearly documented and communicated laboratory protocols." In other words, the physician doesn't need to wait for the results and then place a new order for the culture if he agrees to the reflex protocol when placing the initial test order.

The lab NCD also lists payable diagnoses that show medical necessity for the urine culture. The findings that you mention -- nitrite, esterase, and leukocytes -- are indicative of a possible urinary tract infection (UTI). You can report the findings as 791.9 (Other nonspecific findings on examination of urine), which is a payable diagnosis under the NCD.