Pediatric Coding Alert

Be sure you have the right code, whether you test for 1 element or all 10.

Urinalysis may seem like a simple test commonly performed in pediatric practices, but the not-so-simple requirements for performing this test can help you understand which code applies to your case and when you should append modifier QW (CLIA waived test).

Start With the Common Factors

To ensure proper coding of urinalysis tests, review the requirements for each of the following codes:

• 81000, Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy
• 81001, ... automated, with microscopy
• 81002, ... non-automated, without microscopy
• 81003, ...automated, without microscopy.

The test: The dip stick (or chem-strip) method involves a strip with squares, which the tester quickly dips into the urine. After a specified time the squares change color as each reacts to a different substance in the urine.

For the tablet test, the tester brings the tablet in contact with the urine sample according to manufacturer instructions (such as dropping the tablet into a tube with a diluted sample). The tester waits for a reaction to occur, which again results in color change of the urine specimen.

In both cases, the color changes reveal the results when compared against a manufacturer-supplied key color chart.

Constituents: The codes apply to testing "any number" of the listed constituents, so whether you test for one of the items or all of them, you should report a single unit of the appropriate code, says Joan Gilhooly, CPC, PCS, CHCC, president of Ohio-based Medical Business Resources. For instance, a single unit of 81002 would apply to either a non-automated tablet test without microscopy for ketones or a non-automated chem-strip test without microscopy for all 10 elements.

Master Automation and Microscopy to Distinguish Codes

To choose the proper code for your case, you must determine whether the test is automated and whether it includes microscopy, as shown below:

Non-automated: If the tester compares the test result colors to a manufacturer-provided key color chart without using a specialized machine, you should report a non-automated test.

Automated: The automated test method involves using a specialized machine to analyze the reaction. For instance, the tester may place the dip stick in a "strip reader" machine that prints out a report, Gilhooly explains.

Microscopy: To choose a microscopy code, the provider must analyze the urine sample under a microscope looking for elements such as cells, crystals or bacteria.

Clue In to QW With CLIA-Waived List Tip

One added element you must consider is whether to append modifier QW to your UA code.

Modifier QW indicates you're reporting a test given waived status under the Clinical Laboratory Improvement Amendments (CLIA). To perform waived tests, a practice doesn't need to meet the requirements mandated for more complicated tests, but the practice does need a CLIA certificate of waiver (www.cms.gov/CLIA/downloads/HowObtainCertificateofWaiver.pdf).

Watch out: Just because Medicare oversees CLIA implementation doesn't mean you're exempt from its regulations. Even though pediatricians don't have Medicare patients, you still should follow CMS' lab-test coding guidelines. Why? HIPAA requires that you code consistently, so since some Medicaid payers require modifier QW, the CMS standard gives you a benchmark to follow to code in a uniform way for these tests.

If you look at the current CLIA List of Waived Tests, you will see 81002 listed on the first page. Keep searching and you also will find entries for 81003-QW (download the list from www.cms.gov/CLIA/10_Categorization_of_Tests.asp).

Coding point: The list shows 81002 without QW because the modifier isn't necessary for this code, says Patricia A Trites, MPA, CPC, CEMC, CHCC, CHCO, CHP, CMP(H), CHAP, founder and VP emeritus of Compliance Resources in Sherman, Texas.

All of the tests that fall under 81002 are CLIA-waived, regardless of manufacturer. Consequently, 81002 does not require QW "because the tests are inherently waived and never need to be distinguished from tests that do not have the CLIA-waived designation," explains Helen Avery, CPC, CHC, CPC-I, corporate revenue integrity senior manager with California-based Dignity Health.

In contrast, some 81003 tests are CLIA-waived while others are not. "You would not use QW for 81003 unless the kit/reagent used to perform the test matches both test name and manufacturer as it appears on the list," says Avery. 

Example: Your practice performs urinalysis using the Roche Diagnostics Urisys 1100 Urine Analyzer. Because Urisys 1100 is on the waived-tests list, report the service as 81003-QW.

Leave QW Off of Microscopy Codes

Two codes you won't find on the CLIA-waived tests list are 81000 and 81001. Instead of being CLIA-waived, these codes are on the Provider-Performed Microscopy Procedure (PPMP) list because both require microscopic evaluation of the urine specimen, says Avery.

You should not use modifier QW with these PPMP codes. But you also should be aware that your practice may perform (and therefore report) these tests only when it meets specific requirements.

"To perform these services, the provider must have a CLIA certificate of PPMP (provider-performed microscopy procedures)," explains Trites. "They may not be performed by a lab with only a waived certificate," she adds.

Another important PPMP requirement is that only the physician or a midlevel practitioner may perform the microscopic examination, notes Gilhooly. (You'll find additional specifics at www.cdc.gov/clia/ppm.aspx.)

Final caution: "Some states have their own CLIA department in their state HHS [Health and Human Services] divisions," says Trites. When that's the case, "the providers must use the state list and not the federal list to determine which tests are in each of the categories. Many times states will classify tests that are considered waived on the federal list as moderate on their own lists," Trites says.