Urinary tract infections (UTIs) are quite a common condition in elderly patients, diabetic patients, and pregnant women. To diagnose this condition, physicians require a urine culture test. The test helps identify the type and count of bacteria in the urine.
CPT code 87086 is used in medical billing to report this diagnostic test. However, more detailed guidelines about the billing and reimbursement of this code can be found below.
CPT Code 87086 – Description
CPT code 87086 indicates a lab test for a bacterial urine culture. The American Medical Association (AMA) maintains this CPT code under the ‘Microbiology Culture and Typing Procedures’ codeset.
This culture test is like a quantitative test for bacteria in urine. It provides an accurate count of bacterial colonies in the sample, which further helps in the diagnosis of UTIs. During this, the provider (a microbiologist or pathologist) takes a urine sample and performs the culture test in a laboratory. He analyzes the catheterized collection or clean catch of a sample and then reports the quantitative colony count result if growth is detected.
Scenarios Where CPT Code 87086 is Applicable
The following are some scenarios where CPT code 87086 applies.
Dysuria
Suppose a 32-year-old female with diabetes visits the hospital outpatient department complaining of a burning sensation during urination. The physician takes the necessary history and suspects dysuria (painful urination). So, he orders a urine culture test to identify the microorganisms causing this pain. The pathologist at the laboratory takes a clean catch of a urine sample to observe the bacterial growth in the sample. He can bill his services using CPT code 87086 to represent that he has performed a quantitative urine culture test.
Hematuria
Suppose a 50-year-old man visits a physician’s clinic complaining that he is noticing blood in his urine (hematuria). After asking the patient a few necessary questions regarding his condition, the physician orders a urine culture test to diagnose a UTI or any other serious condition. The professional at the lab can bill the test with CPT code 87086.
Recurrent UTIs
Consider a situation in which a 45-year-old woman with diabetes visits her physician complaining of frequent urinary tract infections. She informs the physician that she continues to experience pain while urinating every three months, even after taking antibiotics and other medications. The medical professional requests that she undergo a urine culture test to determine the type and quantity of bacteria causing this recurring infection. The microbiologist at the test site performing this diagnostic test will bill her services using CPT code 87086.
Applicable Modifiers for CPT Code 87086
Typically, this code does not require a modifier. However, you can apply modifier 59 to CPT code 87086, depending upon the situation.
Modifier 59
Modifier 59 will be applicable if you performed other services that were distinct from the urine culture test on the same day for the same patient. This modifier will help you avoid duplicate-claim denials.
CPT Code 87086 – Billing & Reimbursement Guidelines
The following are the billing and reimbursement guidelines for CPT code 87086.
Provide Proper Documentation
Correct documentation is the most important component of the billing standards. Without a doubt, you will not receive the appropriate reimbursement if you are unable to provide the required and accurate information. First and foremost, the medical necessity of the procedure must be stated in your documentation. You must use the appropriate ICD-10 codes that correspond to CPT code 87086 to demonstrate the necessity of a urine culture test. Additionally, the patient’s information (including medical history), the physician who ordered the test, and any symptoms that raise the possibility of a UTI must be included in your documentation.
Ensure Correct Use of 87086
According to its description, CPT code 87086 denotes a urine culture test typically used to diagnose urinary tract infections. So, you may submit this code if the test was conducted to determine the type and number of bacteria in the urine sample.
On the other hand, if the urine culture test was done for management and assessment reasons, then CPT code 87086 does not apply in this situation. The payer may refuse to pay for the test if this code was not utilized to report a diagnostic service.
Bill Once Per Session
The term “bill once per session” means that you can bill CPT code 87086 once in an encounter. Put simply, the provider will only bill once for all urine samples collected during a single visit, regardless of the number of samples obtained. The provider may bill CPT 87086 again for the new visit if the patient returns on a different day, which is a new encounter.
Follow Payer Policies & Guidelines
Last but most importantly, you must check the payer’s guidelines before submitting your claims for any CPT code. Medicare has provided a clear guideline of the limitations of CPT code 87086 and its acceptable application for reimbursement in their policy manual. Furthermore, for private insurance payers, you must check their specific rules and guidelines for the rightful reimbursement of this code.
Final Word
In short, CPT code 87086 is used to report a urine culture test. However, the catch is that you can use this code for the diagnosis of bacterial infection in the urine, such as UTIs. Microbiologists and pathologists typically conduct this test to identify the type of bacteria and their count responsible for the issue.
Hopefully, this comprehensive guide has covered the important details necessary for the accurate billing of this code. However, if there is still a doubt or you have received a claim denial on this code, you can hire professional pathology billing services to ensure fair reimbursements.
