Don’t know the right code for a manual urinalysis? We have got you covered! Urinalysis is one of those routinely performed tests. Typical reasons? It detects a wide range of conditions and is also a valuable tool in preventive care. So, we can safely assume that you know your way around its different components and examinations.
But what do you know about its coding? It is very common to miscode this test, as each testing method has a specific code. With our help, you can learn the difference between them. Our topic of discussion today? CPT code 81002. Read on to understand what this code covers and how to bill it the right way from the beginning.
CPT Code 81002 – Description
CPT code 81002 refers to a non-automated urinalysis. In simple terms? It specifies a manual interpretation of urine testing without microscopy. So, how does this process go? A lab technician, a pathologist to be more specific, collects a fresh urine sample. He then dips a stick or places a tablet reagent in the sample and waits for a reaction. After the strip or tablet changes color, he uses a color-coded chart to interpret the results.
The entire process is manual, and the provider does not use a microscope to detect the presence of various substances in the sample. In short, CPT code 81002 covers a rapid test for analyzing various components of the urine, including:
- Bilirubin
- Glucose
- Hemoglobin
- Ketones
- Leukocytes
- Nitrite
- pH
- Protein
- Specific Gravity
- Urobilinogen
Scenarios Where CPT Code 81002 is Applicable
Sometimes, the description of a code is not enough. Therefore, practical examples are necessary for the missing context. Want to use CPT code 81002 accurately? Pay attention to the following scenarios:
Diagnosing a Urinary Tract Infection (UTI)
UTIs are the most common outpatient infections. Their common target? Women between the ages of 16 and 35! So, for our first scenario, suppose a 23-year-old woman on diaphragm birth control develops a urinary tract infection (UTI).
After enduring burning pain during urination for some time, she finally visits an outpatient primary care clinic. The healthcare provider evaluates her condition and suspects a urinary tract infection. Hence, he sends a sample of her urine to the lab for a rapid non-automated urinalysis without microscopy to confirm his suspicion. CPT code 81002 is used to bill for the test.
Diagnosing Kidney Infection during Pregnancy
We all know how similar bacteriuria (presence of bacteria in urine) is to a UTI. However, you can have bacteriuria without having a UTI. Did you know that 1.8 to 30% of pregnant women with untreated asymptomatic bacteriuria develop pyelonephritis (kidney infection)? This infection is most common in the second trimester.
So, for our second example, let’s envision a 27-year-old pregnant woman. Suppose she starts experiencing fever, chills, and pain during urination in her second trimester. Concerned about her condition, she visits her gynecologist and describes her symptoms. The healthcare provider orders a urinalysis to discover the root cause.
She collects the patient’s urine sample and sends it to the lab. A lab technician then dips a stick in the urine and, after some time, uses a color-coded chart to interpret the results. Since the test is for diagnosing a new condition, it is not part of the patient’s prenatal care package. Therefore, the technician uses CPT code 81002 to file a claim.
Monitoring a High-Risk Diabetic Patient
For the final example, let’s use the scenario we discussed in the CPT code 81003 blog about monitoring a type 2 diabetic patient. A little background: the patient is 47 years old and has an inactive lifestyle. The main problem? He is at a higher risk of developing kidney disease.
Hence, when he arrives for his annual screening, the physician orders a non-automated urine test. A lab technician collects the patient’s urine specimen and uses a dipstick to perform the test. After the stick changes color, he uses a color-coded chart to note the presence of substances in the patient’s urine. He performs this assessment without microscopy. Hence, he reports it with CPT code 81002.
Applicable Modifiers for CPT Code 81002
Want to adhere to payer policies and guidelines? Use the following modifiers with CPT code 81002, if applicable:
Modifier QW
Did you know that a non-automated urinalysis without microscopy is a CLIA-waived test? You do now! Therefore, use modifier QW with CPT code 81002 before submission.
Modifier 59
Was the manual urinalysis you performed not a component of another service or test? Append modifier 59 to CPT code 81002. This modifier will indicate that the test was distinct from other services performed on the same day.
Modifier 91
Billing for a repeated urinalysis on the same day? Apply modifier 91 to CPT code 81002 to specify that you performed the test again due to medical necessity.
CPT Code 81002 – Billing & Reimbursement Guidelines
So, what are the rules for billing CPT code 81002 correctly? Just keep the following in mind:
Use 81002 for Non-Automated Urinalysis
Don’t fall for the common coding pitfall! Many coders confuse CPT code 81002 with 81003 because they both refer to a urinalysis without microscopy. However, keep in mind that the former covers a manual method for testing urine while the latter refers to an automated technique.
Therefore, use 81002 only when you have used a color-coded chart to manually interpret the urine sample.
Document the Test Details
We say this every time, but documentation is necessary for justifying the medical necessity of any service. Payers always want to know why you have performed a specific service, and yes, this includes tests as well. Therefore, document the following urinalysis details in the patient’s medical record:
- Rationale for performing the test
- Testing tool used (dipstick or tablet reagent)
- Urinalysis method (non-automated without microscopy)
- Urinalysis result
Comply with CLIA Regulations
As mentioned in the previous section, manual urinalysis is considered a CLIA-waived test. Want to know why? Because the CDC/FDA considers it to be so simple that it has a low risk of errors. Therefore, the tedious CLIA regulations do not apply to this simple urine test. However, you must obtain a certificate of waiver and append modifier QW to CPT code 81002 when billing for this test.
Verify Payer Policies for Urinalysis
Another reminder? Always verify individual payer policies before filing a claim for any laboratory test, including non-automated urinalysis. This will save you from unnecessary rework, denials, or even potential fraud cases.
Summary
CPT code 81002 is a popular urinalysis code. Therefore, you should be familiar with its details to avoid confusion with CPT code 81003. It refers to rapid urine testing via dipstick or tablet reagent. The primary distinction between 81002 and 81003? Interpretation method! CPT code 81002 covers manual interpretation without microscopy. Hence, providers use it when they analyze a urine sample without a machine.
From modifiers to billing requirements, we have discussed every important detail about this code in our blog, so you can apply it correctly. However, if you want to avoid revenue leakages permanently, it is better to let a professional handle your coding. You can choose our clinical lab billing services to get a much-needed break from billing.
