Primary Care Coding Alert

Question: The provider ordered a urinalysis as part of a child wellness check. The test came back abnormal. The patient came back the following day for a recheck, but this time the test came back normal. How would I code each encounter?

Idaho Subscriber

Answer: Let’s start with the first encounter. You’ll need to code for the child wellness check using the age-appropriate code from 99381-99395 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual …). Additionally, as the preventive evaluation and management (E/M) uncovered an abnormal finding, you can also bill 99213 (Office or other outpatient visit… low level…) based on the ordered and reviewed test and a self-limited or minor condition that presents a low risk of morbidity from additional diagnostic testing or treatment. To identify the office/outpatient E/M service as significant and separate from the preventive service, be sure to append 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) to 99213.

Next, you would code for the tests themselves, if they were performed in-house. In this case, that would likely mean reporting the appropriate code for the urinalysis, such as 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) or 81003 (…automated, without microscopy).

Keep in mind: Typically, in urine rechecks like this on a different date of service, you won’t be able to justify the medical necessity for a significant, separate office/outpatient E/M unless your provider performed one. Instead, you’ll simply use the appropriate urinalysis lab code again for the test along with Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm).