Wiki Can you bill for UA done in office with only documentation being the results?

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A patient came in to PCP's office to do a urine sample- the MA did a urine dip. They billed for 81002 but I do not have documentation by a nurse or doc indicating the patient was here.... I know the patient was because the results are in chart. My question is are the urine results proper documentation to support billing 81002? At my previous practice the MA always did a note with why patient coming in for urine sample and what physician was in the office...etc. and included the results. Newer to auditing and needing some advice. Thank you!
 
Lab services must be medically necessary. The provider ordering the test/collecting the test must note in the patient's record the reason for ordering the test (or the reason must be easily abstracted from the records), the results and the plan of care based on the results, including when the results are negative. Often times offices will use what is commonly referred to as "standing orders" for certain basic tests such as UA's (81002) but the reason for the test (med nec) still needs to be documented or this would count as missing documentation during an audit.
 
Agreed, you need an order and reason for the test in order to bill. But if you have that, then having the results documented is sufficient to bill for the test - there's no requirement that the nurse or MA document that the patient was there. There is no face-to-face component of a lab service.
 
If billing 81002 with an E/M 99213 or 99214 does a 25 mod need to be on the office visit if where rec denials?
 
Kelsey07 said:
If billing 81002 with an E/M 99213 or 99214 does a 25 mod need to be on the office visit if where rec denials?
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In my experience, (in Michigan) only payer that requires a 25 mod on e/m with a UA is Aetna. If it denies and 25 is not issue it could be an issue with your CLIA #??
 
An E&M and a office UA performed on the same date of service would not warrant the use of the modifier 25.
 
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