Pathology/Lab Coding Alert

Question: The lab performed a urinalysis with microscopic examination for a patient with blood in the urine and painful urination. The physician also ordered a culture. We billed for 81001-QW and 87086 with ordering diagnosis code Z11.2 but the claim was denied. How can we code this correctly?

Oregon Subscriber

Answer: You should use the reported signs and symptoms as the ordering diagnosis in this case. That means reporting a code such as R30.- (Pain associated with micturition) or R31.- (Hematuria) instead of screening code Z11.2 (Encounter for screening for other bacterial diseases). The payer may have denied the claim for lack of medical necessity because you used a screening code rather than a specific symptom code.

UA: Assuming that the lab performed an automated urinalysis for at least some of the 10 specific analytes (constituents) listed in the code, as well as microscopic examination of the specimen, the correct code would be 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). Although several urinalysis codes are on the waived list for Clinical Laboratory Improvement Amendments (CLIA) tests, 81001 isn’t one of them, so you should not report modifier QW (CLIA waived test). That’s because 81001 requires a lab with microscopy certification, not waived-status certification.

Culture: You’ve listed the correct code for a urine specimen culture, which is 87086 (Culture, bacterial; quantitative colony count, urine). Remember that if the culture is positive and the lab presumptively identifies the organism you should additionally report 87088 (… with isolation and presumptive identification of each isolate, urine) for each isolate.