Urology Coding Alert

Plus: 2 tactics help keep tech troubles from derailing your coding.

To be sure your documentation supports reporting a urinalysis (UA) code, you need to have a signed order for the urinalysis and proof that your practice rendered the service.

Here's how these requirements affect the codes discussed in " 81000-81003 Know-How Requires a Closer Look at Urinalysis Methods" in Urology Coding Alert Vol. 14, No. 5:

• 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.

Create a Plan to Ensure Written Order

Medicare has specific requirements for ordering diagnostic tests. But in an office setting, the urologist and nurse are talking constantly, so overlooking the written order is an easy mistake to make, warns Joan Gilhooly, CPC, PCS, CHCC, president of Ohio-based Medical Business Resources.

If you have an electronic medical record (EMR) with a designated spot for orders, make it standard practice to include orders there. If you don't use an EMR, work with providers to ensure the medical record contains a written order. Including the order in the progress note is fine because the urologist's signature on the note acts as a signature for the order, Gilhooly says.

Microscopy must: To support using the microscopy codes (81000, 81001), the order must specify microscopy. Otherwise, auditors will reduce the service to a "without microscopy" code. (For example, this WPS Medicare document states, "If the intention is to order a urinalysis with microscopy, it must be clearly noted on the order or payment will be reduced": www.wpsmedicare.com/j5macpartb/training/on_demand/_files/diag-handout-3.pdf.)

Plan Ahead for When Machine Breaks

The UA order doesn't need to specify whether the test should be automated (because it is a matter of method), but you will need to know the method to choose the proper code.

Generally speaking, the automated (81001, 81003) method results in a print-out from the machine used. In contrast, the non-automated (81000, 81002) method results in documentation by the tester, says Gilhooly.

Problem solver: If the staff performs an automated test but the machine's printer is broken, the documentation will be by the tester rather than being in the usual printout format. In those cases, the tester should document the test was automated to support use of an automated code, Gilhooly says.

Practices that use the automated method also need to prepare for when machine troubles require the staff to use a non-automated method. Because the practice's standard test is automated, the superbill may include only automated test codes. As a result, staff may circle an automated code for a non-automated test, leading to incorrect coding, says Gilhooly. Prevent this problem by alerting staff to the issue and including both automated and non-automated codes on the superbill.

Audit-Proof Non-Automated Documentation

If your practice uses non-automated testing, one way to simplify documentation is to have a urinalysis form showing each component measured by the test you use. For example, if the dip stick supply you use tests for all 10 elements in the codes, then list each of the 10 elements and allow space after each for the tester to fill in the results, Gilhooly suggests.

You also will want to perform a final check before billing to ensure your documentation ducks are in a row.

Example: A sample case could involve a practice using a lab sheet that records performance of 81000 (dip and microscopy, non-automated) for a patient with mixed incontinence (788.33, Mixed incontinence [male] [female]), says Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. The lab sheet is included as part of the medical record, which additionally includes: "Urinalysis shows no protein, no glucose, no heme, pH5. Micro exam shows rare WBC, otherwise negative. Urine is unremarkable." Before posting the charge, the practice checks the lab sheet against the encounter to ensure the team (1) performed a UA, (2) billed it, and (3) documented it in the EMR, Kater says.