Pathology/Lab Coding Alert

Medicare says "show me a sign" before it will cover bacterial urine cultures. Labs must oblige with documentation and appropriate ICD-9 Codes if they want to get paid for bacterial urine cultures.

The National Coverage Determination (NCD), available on the Internet at http://www.cms.hhs.gov/ncd/searchdisplay.asp?NCD_ID=25&NCD_vrsn_num=2, lists more than 200 ICD-9 codes that show medical necessity for performing 87086 (Culture, bacterial; quantitative colony count, urine) and 87088 ( with isolation and presumptive identification of isolates, urine).

"These diagnosis codes describe indications outlined by Medicare for bacterial urine culture," says Anne Pontius, MBA, CMPE, MT (ASCP), president of Laboratory Compliance Consultants Inc. in Raleigh, N.C. "Laboratories should try to secure a signed advance beneficiary notice (ABN) when the diagnosis from the ordering physician indicating medical necessity is not included on the NCD ICD-9 list."

The ICD-9 codes fall into five primary categories, according to Medicare:

1. Abnormal urinalysis: Physicians often order urinalysis, with urine culture dependent on initial positive or abnormal test results. Findings that point to proceeding with a culture might include abnormal microscopic findings such as hematuria (599.7) or pyuria (791.9), abnormal biochemical findings such as protein in urine (791.0), or positive Gram stain.

2. Clinical signs and symptoms of urinary tract infection (UTI): Symptoms may include urination frequency (788.41), nocturia (788.43), dysuria (788.1) or abdominal pain (789.0x). Elderly patients or those with neurologic or immunologic disorders may have atypical symptoms such as debility (799.3).

3. Signs and symptoms of sepsis from unknown source: Indications include fever of unknown origin (780.6).

4. Response-to-therapy evaluation for complicated UTI: Complications that indicate a urine culture to evaluate UTI response to treatment (599.0) may include abnormalities such as calculi (594.x) or signs and symptoms indicative of continuing UTI such as those listed in number 1.

5. Genitourinary surgery/renal transplant: Preoperative urine culture (V72.84) to detect occult infection may be indicated for surgeries such as renal transplant, kidney stone removal or transurethral bladder surgery.