Urology Coding Alert

Question: What is the appropriate modifier to use with 81003 for an automated test without microscopy when I am billing an E/M code as well?  

Maryland Subscriber

Answer: For payment on 81003 (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, without microscopy), many payers, including Medicare, will require that you append modifier QW (CLIA waved test).

Some private and commercial payers will also refuse payment and will consider the urinalysis part of or bundled with the E/M service. You should appeal these decisions. Also, consider appending 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 the E/M service, depending on the payer.

For example: Aetna will pay for both the urinalysis and E/M visit when the coder attaches modifier 25 to the accompanying E/M code.