Pathology/Lab Coding Alert

Question: The lab ran a urine culture that the physician ordered because the patient was experiencing burning during urination. The culture was negative, but the lab noted occult blood in the urine. How should we report the culture and the diagnosis?

Virginia Subscriber

Answer: The correct code for the negative bacterial urine culture is 87086 (Culture, bacterial; quantitative colony count, urine). Because you did not isolate an organism, you should not additionally code 87088 (& with isolation and presumptive identification of each isolate, urine).

Exception: Unlike other culture sources that have a single CPT code to describe a positive culture and presumptive identification, urine requires two codes to report the same work (87086 and 87088). But because your culture was negative, you should not report both codes.

If the physician ordered the urine culture with a narrative diagnosis of burning during urination, the correct ICD-9 code is 788.1 (Dysuria). As a laboratory, you should report the ordering diagnosis or the reason for the test.

The lab should not assign a diagnosis based on test findings. The physician will determine the final diagnosis based on clinical observations as well as lab test results. In this case, the physician might assign 599.72 (Microscopic hematuria) and order further tests to discover the cause of the condition.