Pathology/Lab Coding Alert

Question: A physician ordered an automated urinalysis with a microscopic exam for retrograde ejaculation. Should we report 81001 for automated urinalysis with microscopy?

Tennessee Subscriber

Answer: No, 81001 (Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy) is not the correct code for the service you describe.

Although in the past you would report 81015 (Urinalysis; microscopic only) for a microscopic exam to evaluate sperm in urine, CPT 2008 has a new code for the service. Now you should report the test as 89331 (Sperm evaluation, for retrograde ejaculation, urine [sperm concentration, motility and morphology, as indicated]).

Old way: Before the code change, you would be correct to bill 81001 for the urinalysis and microscopic urine exam. You should not fragment a service and report it with multiple codes when a single code describes the service -- such as reporting 81003 (- automated, without microscopy) and 81015 instead of 81001.

New way: Because you have a new code for the retrograde sperm evaluation, you should code that as a distinct test in addition to the automated urinalysis without microscopy.

Report 81003 and 89331 for an automated urinalysis with a microscopic exam for retrograde ejaculation