Pediatric Coding Alert

Question: For all lab tests performed in the office, our nurse researches the history, collects the sample, then gets the results. Can I therefore bill 99211 with urinalysis code 81002?

Oregon Subscriber

Answer: No. CPT^® guidelines prohibit reporting 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional) with 81002 (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, without microscopy) in the outpatient setting, though no National Correct Coding Initiative (NCCI) edit exists for 81000-81003 (Urinalysis…) when the tests are Column 2, or component, codes for office/outpatient E/M services 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient …).

That being said, when reporting 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional), there must be some “evaluation and management” of the patient. Obtaining patient history and getting results doesn’t count as a true evaluation and management service. Billing an evaluation and management (E/M) service requires that the patient have an exam, discussion of symptoms, medical decision making, consideration of possible diagnoses, and a treatment plan needs to be made, including discussion with patient about how to move forward, etc.

If there is a true E/M service, most of the time you’ll report the tests and an office/outpatient E/M service separately, because they are distinct services and the order for the test is often the result of an E/M service.

So, the urinalysis is usually separately reported in addition to an E/M, but some payers may require a modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] appended to the E/M.

In cases where payers deny 81000-81003 as bundled into an office/ outpatient E/M, you can also try appending modifier 59 (Distinct procedural service) to the 81000-81003 codes to see if that overrides the edit in question.

Note: Remember also that 99211 exists as an incident-to code. In order to bill 99211 at all, the physician needs to have delegated the service to a nurse. In other words, if the physician does not see the patient, but the nurse thoroughly evaluates and manages (as described above), and the supervising physician is in the building, you can bill 99211 under the physician’s credentials. If the physician does end up seeing the patient, then the physician would end up billing something higher than 99211, such as a 99212 because then the encounter is then outside of the incident-to criteria.