Revenue Cycle Insider

Question: Can I bill a dip stick urinalysis conducted in-house, within our practice?

New Mexico Subscriber

Answer: Practices can perform urinalyses in house if they obtain a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver.

Once you have a waiver, you need to make sure you have the correct types of documentation: a signed order for the test, as well as proof that it was conducted in your practice.

Note: The order should specify whether the test will involve microscopy; tests that don’t involve microscopy are simpler and less expensive, and an auditor who sees a service without the specification might downgrade to a service not involving microscopy.

Here are the types of urinalyses an office with a CLIA certificate of waiver might perform:

• 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)

Make sure you understand the processes described in the code descriptors:

• Non-automated tests involve comparing the color changes on a test strip after it has been placed in the urine sample to a color chart provided by the test manufacturer. This can also be done by placing a reagent tablet in the sample, which changes the color of the urine (codes 81000 and 81002).
• Automated tests involve a machine that analyzes the test strip automatically (codes 81001 and 81003).
• Microscopy tests involve viewing elements in the urine sample such as bacteria or crystals using a microscope (codes 81000 and 81001).

So, in your example, if your tester views a test strip manually without using a microscope for further analysis, you could select urinalysis code 81002.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC