Urology Coding Alert

Understanding what ‘constituents’ entail will help you code correctly.

Urinalysis testing is so routine at many urology practices that you may have the process of coding and billing these services committed to memory. But in some cases, missing just one small step can lead to mistakes, and auditors are finding more and more errors among these claims.

Background: CBR Pepper, which the Centers for Medicare & Medicaid Services (CMS) contracts to produce comparative billing reports (CBRs), recently conducted a review of urinalysis claims. The firm sought to evaluate why the government found a 10.8 percent improper payment rate for urinalysis testing in 2022, representing more than $3 million in improper payments. In the resulting analysis, released in March 2023, the organization indicated that auditors have ramped up reviews of urinalysis claims to look for opportunities to recoup reimbursement for these services.

Check out three quick tips to ensure your urinalysis claims are compliant and positioned for swift and accurate payment.

Before you start: “Remember that medical necessity is important when reporting urinalysis tests. Make sure there is a documented reason for a urinalysis in the patient’s medical chart,” says Stephanie Stinchcomb Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coder and consultant in Glen Burnie, Maryland.

1. Don’t Report 81001 Without Microscopy

During a 2022 Comprehensive Error Rate Testing (CERT) review, Part B contractor Noridian Medicare found that a common issue among urinalysis claims was when a provider reported 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), but the physician’s order only supported 81003 (…automated, without microscopy).

The key difference: The descriptor for 81001 notes “with microscopy,” so if your practice doesn’t perform microscopy, you must instead report 81003.

The documentation should indicate which testing method the urologist ordered. To confirm that, you’ll need to know the different processes mentioned in the code descriptors:

Automated tests involve a machine that analyzes the test strip automatically (codes 81001 and 81003).

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. If a non-automated test is performed, 81001 and 81003 are not the right codes. For these, you’d instead report 81000 (…non-automated, with microscopy) or 81002 (…non-automated, without microscopy).

Microscopy tests involve viewing elements in the urine sample, such as bacteria or crystals, using a microscope.

If the order doesn’t denote the need for a microscope, then auditors won’t be able to justify your practice reporting 81001.

Tip 2: ‘Constituents’ Won’t Match Units

When you review the urinalysis codes, you’ll typically choose a code from the 81000-81003 range. These codes list the types of tests they apply to (for instance, glucose, hemoglobin, bilirubin, etc.), followed by the phrase, “any number of these constituents.”

Some coders get tripped up by this phrase and don’t realize that the term “constituents” refers to the specific elements for which you’re testing the urine. In some cases, coders then report the codes using 1 unit per element rather than submitting a single unit of the code to cover them all.

For instance, if you use microscopy and automated testing to evaluate a patient’s urine for nitrites, pH, protein, and hemoglobin, that’s four constituents. However, you wouldn’t be submitting 4 units of 81001 to the payer. Instead, all those elements are covered under a single unit.

If the constituents that your urologist tests aren’t listed in these descriptors, then these aren’t the right codes for you. Depending on the elements the urologist orders, you might choose from the 81005-81015 range, as appropriate and depending on the documentation.

Tip 3: Check With Payer on E/M Modifiers

In many cases, the urologist will perform an evaluation and management (E/M) service before ordering the same-day urinalysis. In this case, you may wonder if you’re billing compliantly by reporting both an office visit code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient …), and the urinalysis code.

The current National Correct Coding Initiative (NCCI) edits do not bundle 81000 (or the other common urinalysis codes listed above) with 99213 or other E/M codes.

That means you can submit both codes on the claim, but you might still occasionally run into reimbursement obstacles. Some payers might expect you to report a modifier such as 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) with 99213 or 59 (Distinct procedural service) with 81000 before reimbursing for both codes during the same encounter. Check with the payer to see if this is the case and whether they expect particular documentation supporting the service.

Resource: To read the CBR on urinalysis, visit https://cbr. cbrpepper.org/About-CBR/CBR-202303.

Torrey Kim, Contributing Writer, Raleigh, N.C.